Charles MacLean, MD, primary care internal medicine physician, provides insight on Vermont’s opioid crisis in this Q&A.
Q: Much has been made in the media about Vermont’s opioid crisis. Can you give us some insight into how we got here?
A: About 20 years ago, there was the sense that we were under-recognizing and under-treating pain. To address that, we began thinking of pain as the fifth vital sign, measuring a patient’s pain became a priority for primary care medical professionals, and in general this created more of an awareness around the debilitating effects of chronic pain.
Over time, and for a lot of complicated reasons, we probably pushed the pendulum too far and ended up over-using opioids for chronic pain. And that, in some cases, has led to diversion, misuse and addiction.
Q: But isn’t there still a role for opioids in treating pain.
A: Absolutely. Opioids work well for acute pain, for example after surgery. But the jury is out on opioids and chronic pain. Why? First, you have the issue of the body developing a tolerance, so you need more of the drug for them to work – and then you have the addiction potential. Another issue is side effects, which increase when you have to keep upping the dosage for effectiveness. Finally, for some conditions such as migraine and fibromyalgia evidence shows that opioids can make the problem worse. In the case of chronic non-specific low back pain – which is the most common reason for prescribing opioids – the jury is still out on where the balance is between risks and benefits.
Q: So what does all this mean when someone with chronic pain comes in to see their doctor?
A: A major change in how we approach prescribing for pain is that now we are less focused on pain and more on function, or “what can you do every day?” So, if the opioids improve your ability to participate in work or school, or help take care of a family member, then they may be the right choice. This doesn’t mean we ignore pain – but the patient’s level of function should be the primary focus. In addition, when we do determine that a course of opioids is an option, we start with a frank discussion focused on the concept that this is a trial, and if the treatment is not working we will taper the meds and try another approach. By starting out with that set of expectations at the beginning of the treatment, you have a clearer exit strategy.
A final point that I would like to highlight is that the level of community awareness around the risks of opioids has greatly increased over the past two years. Increasingly, patients are coming in aware of the risks – and are often reluctant to try them. This makes it easier to have the kind of frank discussions that we need to have, to ensure that our patients are receiving the most effective and safest treatment possible.