Right care for chronic pain in primary care
Primary care clinicians accounted for about half of all opioid prescriptions in the US from 2007-2012. Overprescribing of opioids can lead to dependence and serious harm, but abrupt tapers or discontinuation can also be disruptive for patients already taking opioids. How can primary care clinicians prescribe pain medications responsibly?
In the latest edition of the “Right Care Series” in the journal American Family Physician, primary care doctors Alan Roth and Andy Lazris, and patient partners Helen Haskell and John James review the evidence and provide guidance for how to prescribe for patients with chronic pain in a patient-centered way.
For patients dealing with chronic pain (pain that does not subside for three months), the first line of treatments should be nonpharmacologic treatments such as physical therapy, or nonopioid medications such as acetaminophen and NSAIDs. Adjuvant medications such as antidepressants or anticonvulsive medications can also be helpful, but clinicians and patients should be aware of potential drug interactions and side effects.
The authors recommend that before prescribing opioids, clinicians should assess the benefits and harms of the medication with the patient, prescribe the lowest possible dose, and implement mitigation strategies to decrease the potential for misuse. These mitigation strategies include prescription monitoring programs, prescribing naloxone, and making sure not to prescribe benzodiazepines like Xanax or Klonopin along with opioids (a combination that can lead to severe adverse events).
Just as one should start with the lowest possible dose of opioids, any reductions should also be carefully tapered, at a rate of 10% each month. The authors note that with the CDC’s 2016 guidance, many primary care doctors abruptly stopped prescribing opioids or dropped patients, even some who had been taking opioids for chronic pain for a long time. This overcorrection was not based in evidence and likely harmed patients, some doctors claim.
The potential harms of opioid addiction have been well-established in the media, but patients may not be as aware of the potential harms of other drugs commonly prescribed for pain. “As part of shared decision-making, patients should be made aware of concerns about long- term use of acetaminophen causing liver damage or use of NSAIDs causing cardiovascular, bleeding, or gastrointestinal effects,” Haskell and James write. The side effects of other drugs commonly prescribed to treat pain such as muscle relaxants or antidepressants should also be discussed. Just because it is not an opioid, does not mean it is harmless.