A good solution also has to work within the framework of the social and emotional context surrounding chronic pain. One important thing to confront, said Dr. Hood, was the “unspoken assumption that you need a controlled substance” for certain types of pain.
Although it’s not supported by the medical literature, there’s “still this tug from the patient that you’re holding something back from me” if a complaint of pain, especially chronic pain, doesn’t get an opioid prescription. The continued widespread use of an unproven treatment in chronic pain care stands out from other areas of medical care, where evidence-backed treatment is increasingly the norm, Dr. Hood noted.
Part of changing the conversation within a practice, and then expanding the dialogue to include the patient, is to reframe the discussion.
“It’s not more care or less care, but different care,” said Dr. Hood. He spoke of a patient who had been on very high opioid doses – equivalent to 200 mg morphine daily – for neuropathic pain. Within the framework of the physician-patient relationship and with a lot of talking, Dr. Hood was able to transition the patient to a regimen appropriate for his pain. Within 6 weeks, the patient’s opioid dose was equivalent to less than 80 mg morphine daily, his pain was better managed, and his quality of life was greatly improved.
The significant side-effect burden of opioids often includes a degree of constipation, which many patients won’t talk about, but which is a very real and daily struggle for those who are on high doses. This was the case for Dr. Hood’s patient with neuropathic pain, and the improvement in that symptom alone helped the patient’s willingness to stick with the transition away from an opioid-based regimen.
Keeping the patient at the center of chronic pain care, while still using available tools and knowledge to provide high-quality rational care, is an achievable goal, he said.
“We’ve proved we can make the change, and we’ve proved we can achieve adherence to the regulations,” he said. “Now, how do we further improve the care of the patient? The job’s not done.”
In development are adaptive tablet-based surveys that tailor themselves to patient responses, yielding more accurate information about patient characteristics and substance use profiles in a more user-friendly format.
Dr. Hood and his project collaborators hope to seek grant funding to disseminate the project beyond the borders of the state of Kentucky. The scalability of the QI process is a strength, he said.
In the process of developing the QI program, Dr. Hood and his collaborators met with key thought leaders in the pharmaceutical industry to build support for educational initiatives such as the ACP Quality Connect program.
As for the sometimes tainted history of the use of opioids for chronic nonmalignant pain? “That’s the past,” Dr. Hood declared. “We now have an opportunity to turn to the future. ... This needs to happen to alleviate the suffering of these patients.”
On Twitter @karioakes