Colleague Interview (Continued from page 11)
What options do you employ when your patient is not cooperative or compliant? Careful informed consent. Professionalism. Never exceeding or breeching one’s personal sense of medical professionalism and medical decision making. Debriefing with colleagues is critical in these instances. An experienced colleague can help navigate these difficult situations.
Many patients on opioids for chronic pain management maintain that they are effective and help them function; however, disability claims from chronic pain conditions such as joint and back pain have continued to increase despite the use of these medications. Do you think opioids are an effective way of getting patients re-engaged in their lives? What would you tell physicians and patients when the medicines seem to provide initial improvement and relief? Opioids alone are not a good way to get people to reengage in their life, and, in fact, in some vulnerable patients, opioids will actively interfere with and undermine their attempts to reengage in life because opioids are so addicting.
What strategies have you found effective in transitioning a patient from acute pain medication use to a chronic pain medication use situation? Please offer some suggested ways to open a conversation about what can be a tricky/hot-button topic. The key point here is twofold. First, differentiate chronic pain from chronic opioid use. They are different. What I suspect this scenario refers to is chronic opioid use, not chronic pain. When a patient is given opioids for an acute event, over time it can become chronic. Then patients can start to develop problems with the opioids, thus the concern. Chronic pain begins technically at 90 days or three months; however chronic opioid use develops much sooner. The state measured this and found that opioid use has already developed chronicity at 45 days, so even that is too late. Basically, physicians should start intervening in the opioid prescription immediately, at the latest at the first refill. Of people taking opioids for pain, 10% get addicted and 30% misuse opioids, so we really cannot be careful enough or act soon enough. If you wait for the 89th day and say “tomorrow it will be chronic pain!” it is way, way too late.
Please outline your treatment approach to a patient severely addicted to opioids. There are three FDA approved and evidence-based treatments for opioid addiction: intramuscular naltrexone, sublingual buprenorphine and oral liquid methadone in a clinic. The first is the new kid on the block and we know it helps but we are not sure if there is mortality benefit. Buprenorphine and methadone are well established to save lives, improve function, reduce HIV transmission, reduce incarceration and improve pregnancy outcomes. In other words not offering one of these treatments to a patient who is addicted is, in my opinion, malpractice that jeopardizes the patient’s life. Also, opioid addicts in an overdose situation should be offered injectable or nasal naloxone which is the opioid overdose antidote and may save their life.
What are your thoughts on the efficacy and the clinical value of an office-based buprenorphine program, and the potential downsides of such a program? This is a life-saving treatment that I believe every doctor in the state who prescribes opioids should strongly consider getting a license and, if not, have a community referral resource. The downside right now is that because so few doctors are reluctant to take on a buprenorphine license, if you get a license you may get a call asking for help every day. I would suggest to doctors starting out with a license to use it on their own patients in whom they themselves caused an iatrogenic addiction. The other downside is that providers need to know when a patient has too severe an addiction, or mental illness, to be managed by primary care. Administering buprenorphine is one of the most wonderful and fulfilling parts of my job. I would highly recommend all community primary care physicians get the license. It is worth it.
Should this be available in a general primary care setting? Yes. Please note that there will hopefully be a new system in the state to support community buprenorphine providers with expertise consultation if they need it.
When psychiatry is the major current presenting problem, how does one manage detoxification in a psychiatric setting? It is more complicated and challenging to detox a patient who is in a mental health crisis. They may need to be in a controlled setting such as a detox center or inpatient psych unit. The physician may want to prioritize mental health treatment and detox, or each disease may undermine the other.
(Continued on page 14) MetroDoctors
The Journal of the Twin Cities Medical Society
March/April 2017
13