Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

We need to speed up our acceptance of the opioid guidelines

Kathryn Takayoshi, NP-C
Meds
December 17, 2016
Share
Tweet
Share

A couple of years ago, I inherited a patient who was on both a patch for the powerful painkiller fentanyl and a high dose of oxycodone four times daily — and she didn’t have cancer.

I had 15 minutes with that patient to get her medical history, review her medications, assess her current complaints, and decide whether or not to continue her opioid prescriptions. I had no paper records and a very poor electronic medical record system. I lacked a lot of the information I needed in order to prescribe such a high opioid dose.

However, if I refused to continue the opioid prescriptions, I would force the patient into withdrawal. I weighed my options and came up with a reasonable plan, but it would have gone much better if I’d had some guidelines to fall back on. Amid the hubbub of the community health center where I work as a nurse practitioner, I felt stuck and alone.

We primary care practitioners want to do what’s best for our patients, including those with chronic pain, who are often some of the most challenging patients to manage. We do not want to overprescribe a potentially addictive and lethal opioid medication. In the primary care setting, all of this decision-making is happening at once, and the patient is waiting for your decision.

At the time I saw that patient on fentanyl and oxycodone, there were no formal guidelines to help me. Every provider on my team practiced differently. Some were quite liberal with their prescriptions; others rarely prescribed controlled substances. It seemed like everyone was making a personal judgment call and no one knew where to turn for proper standards of care.

These clinical decisions are not so clear-cut. For a practitioner, it is emotionally draining and time-consuming to halt opioids for a patient who has been prescribed them for years. Working in a community health center in Lynn, which, like many small New England cities, is ravaged by the opioid crisis, I have not met a single primary care provider who has decided to start opioids for a patient.

Rather, we are dealing with the “inherited” pain patient, who has been prescribed opioids by someone else. These patients usually end up with us because their previous provider left the practice, their insurance changed and they cannot see their old provider, or they burned their bridges and are looking for a new prescriber.

It’s hard to write guidelines for the management of chronic opioid therapy. The Centers for Disease Control finally came out with their first attempt in March of this year. Before that, there were a few government agencies that attempted to write guidelines on the topic, but they were weak at best, and certainly not widely followed.

Our health center decided not to wait, and has been working on our own set of guidelines for the past year. We saw the need, and we stepped in to improve our care. We created a task force that includes primary care providers, RNs, behavioral health clinicians, and an addiction specialist. We looked at existing guidelines, literature on chronic opioids and chronic pain, and expert recommendations.

The CDC guidelines are excellent, but ours go further in focusing on behavioral health and addiction treatment: We require a urine drug screen at each monthly visit. We have fully integrated behavioral health into primary care, sharing the space. Every chronic opioid patient has to get a comprehensive pain evaluation — also a step beyond the CDC. And we have our own suboxone clinic — suboxone treats opioid dependence — though we’re working to provide suboxone in primary care rather than making patients go to a separate clinic.

We are now in the process of spreading our knowledge and putting our guidelines into practice throughout the health center. So far, we have decreased the overall number of patients on risky opioid medications. More specifically, we have greatly reduced the number of those on the highest-risk medication combination: opioids and benzodiazepines. We have also increased our referrals to addiction treatment and improved our access to behavioral health treatment.

If that same patient on the fentanyl patch and opioid pills came to me today, I would be much better prepared. Perhaps more importantly, I would feel more confident and empowered. I now have standards of care and a health-center-wide task force to rely on. I would feel more supported in my decision-making. Patients need to know that they are in good hands. Our work has helped make this possible.

It has certainly been difficult. Providers are initially defensive when it comes to their prescribing practices. This is to be expected. But we need to start looking at chronic pain and opioid prescribing as we do other disease processes.

ADVERTISEMENT

We have studies that tell us that chronic opioid therapy is not effective in improving function (and sometimes even pain) over time. We have studies that tell us that chronic opioids can cause low testosterone levels in males, chronic constipation, and even an increased pain response, among other side effects.

We have experts that tell us to prescribe only low doses of opioids and never to prescribe opioids and benzodiazepines together. We need to listen to these experts. The surgeon general recently sent individual letters to providers pleading with them to reduce their opioid prescribing.

It seems that we are always slow to adopt new guidelines. We are skeptical and resistant to change. This is one of those times when we need to speed up our acceptance. Talking about overprescribing is not enough. Primary care providers are good at following new diabetes guidelines. It’s time we do the same for chronic opioids.

Kathryn Takayoshi is a nurse practitioner. This article originally appeared in WBUR’s CommonHealth.

Image credit: Shutterstock.com

Prev

MKSAP: 34-year-old man with fatigue, low libido, and infertility

December 17, 2016 Kevin 0
…
Next

A blow-by-blow account of daily life with chronic pain and illness

December 17, 2016 Kevin 5
…

Tagged as: Pain Management

Post navigation

< Previous Post
MKSAP: 34-year-old man with fatigue, low libido, and infertility
Next Post >
A blow-by-blow account of daily life with chronic pain and illness

ADVERTISEMENT

Related Posts

  • How do we manage pain in the era of the opioid crisis?

    Rita Agarwal, MD
  • Marijuana will not fix the opioid epidemic

    Kenneth Finn, MD
  • Want to stop the opioid epidemic? Stop prescribing opioids.

    Jenny Hartsock, MD
  • Americans and Canadians use more post-surgery opioid pain pills

    Julie Appleby
  • A patient’s opposition to the anti-opioid movement

    Angelika Byczkowski
  • Take a close look at the number of opioid pills you’re prescribing

    Tia Powell, MD

More in Meds

  • How drugmakers manipulate your health from diagnosis to prescription

    Martha Rosenberg
  • The food-drug interaction risks your doctor may be missing

    Frank Jumbe
  • Why retail pharmacies are the future of diverse clinical trials

    Shelli Pavone
  • Why does rifaximin cost 95 percent more in the U.S. than in Asia?

    Jai Kumar, MD, Brian Nohomovich, DO, PhD and Leonid Shamban, DO
  • A world without antidepressants: What could possibly go wrong?

    Tomi Mitchell, MD
  • The truth about GLP-1 medications for weight loss: What every patient should know

    Nisha Kuruvadi, DO
  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • How community paramedicine impacts Indigenous elders

      Noah Weinberg | Conditions
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
  • Recent Posts

    • Who will train the next generation of primary care clinicians without physician mentorship? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • The CDC’s restructuring: Where is the voice of health care in the room?

      Tarek Khrisat, MD | Policy
    • Choosing between care and country: a dual citizen’s Independence Day reflection

      Kathleen Muldoon, PhD | Policy
    • What Elon Musk and Diddy reveal about the price of power

      Osmund Agbo, MD | Conditions
    • 3 tips for using AI medical scribes to save time charting

      Erica Dorn, FNP | Tech

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 8 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • How community paramedicine impacts Indigenous elders

      Noah Weinberg | Conditions
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
  • Recent Posts

    • Who will train the next generation of primary care clinicians without physician mentorship? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • The CDC’s restructuring: Where is the voice of health care in the room?

      Tarek Khrisat, MD | Policy
    • Choosing between care and country: a dual citizen’s Independence Day reflection

      Kathleen Muldoon, PhD | Policy
    • What Elon Musk and Diddy reveal about the price of power

      Osmund Agbo, MD | Conditions
    • 3 tips for using AI medical scribes to save time charting

      Erica Dorn, FNP | Tech

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

We need to speed up our acceptance of the opioid guidelines
8 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...