Safe opioid stewardship is a key objective when managing chronic pain. Combining evidence-based strategies and compassionate care can help you to realize these goals.
As a primary care doctor serving many adults with complex social and chronic medical needs, my daily schedule frequently revolves around issues of pain.
A recent day started with Mr. M, a broad-chested man in his 50s who had undergone a below-knee amputation due to a diabetic foot infection two years ago. After his surgery, he developed intense phantom limb pain that prevented him from participating in the essential task of rehab to use his prosthesis. With the help of modest dose opioid therapy, he completed PT and continues doing well on a stable regimen that enables him to walk for a full hour every day.
Then I saw Ms. P, a reserved woman in her 40s with chronic low back pain. By the time I met her, she was frequently running out early of the opioids she had been prescribed long-term. Her mood had worsened, and she admitted she was losing control of her opioid use. Over time, we addressed her mood, created some functional goals, and transitioned to treat her pain and opioid use disorder with buprenorphine. Now over a year later, she continues to do well, with improved physical function, mood, and pain.
Later on that day, I saw Ms. S. A lively woman in her 50s, with severe knee osteoarthritis. Committed to postponing knee replacement as long as she could, her pain management plan includes NSAIDs, topical lidocaine, PT, and periodic knee steroid injections—all of which enabled her to get around the house and run errands.
I was fortunate to be able to share lessons I’ve learned from caring for these patients and others in a course on pain for first year medical students that was recently profiled on NPR.
1. Acknowledge and validate pain.
Pain is a subjective experience that all people experience differently. Trauma and mental illness can modulate and amplify the experience of pain. Building mutual trust and believing in a patient’s pain are crucial to addressing it effectively.
2. Focus on function.
Fixation on pain intensity can create barriers to progress, and many patients with chronic pain never achieve complete relief. Functional objectives make progress easier to measure and promote specific quality of life goals.
3. Establish durable patient relationships.
Treatment of chronic pain is best done in a longitudinal relationship with patients. People with chronic pain frequently face stigma and distrust when seeking care. Fragmented healthcare delivery jeopardizes the quality of care and risks alienating patients, which may influence their future approach to healthcare encounters.
4. Recognize the risks of opioid over- and under-utilization.
Medical practice has had a complex relationship with opioids since at least the late 19th century when heroin was introduced as a brand-name non-addictive analgesic. Recognition that these claims were false fueled intense anti-opioid backlash and motivated highly punitive policies that left patients with chronic pain and/or addiction out to dry. There are many parallels in today’s highly charged atmosphere around opioids. Dramatic fluctuations in attitudes toward opioids threaten to harm patients—initially by putting people at risk through over-prescribing, and then through rapid de-prescribing that can lead to psychological distress and pursuit of unregulated illicit opioids.
5. Practice safe opioid stewardship.
Opioid stewardship is crucial and includes three key considerations: practicing judiciousness in initial use of opioids, collaborating longitudinally with “legacy” patients on long-term opioid therapy to address pain and medication-related risks, and providing screening and treatment for opioid use disorder.
Those who prescribe opioids should have the capacity to treat opioid addiction with evidence-based strategies, either within their practice or via referral to a trusted source. Patients with chronic pain who develop opioid addiction are particularly vulnerable and often risk abandonment of treatment of their chronic pain and substance use disorder.