Bridging the doctor-patient divide over opioids

  | October 3, 2016

In exam rooms across the country, chronic pain has created a divide between patients and physicians — built on fear.

Doctors, keenly aware of the national opioid epidemic, are afraid of over-prescribing pills like Oxycontin. Patients are scared that their doctors won’t believe how much they’re hurting and will take their medication away.

One way to end the standoff, addiction experts say, is to teach physicians how to best to talk to patients about pain management — and how to navigate the tricky waters of prescribing opiates over the long term.

That’s the goal of SCOPE of Pain, a training program based at the Boston University Medical School. (The acronym stands for Safe and Competent Opioid Prescribing and Education.)

Daniel Alford, SCOPE of Pain, athenaInsight
Daniel Alford, M.D.

“Everyone wants to solve this problem yesterday,” says Daniel Alford, M.D., who developed the program and directs Boston Medical Center’s Clinical Addiction Research and Education Unit. “Education, in my mind, is the answer, because it allows individualized care — where we allow access for those who need it and not treat with opioids for those who don’t.”

The SCOPE of Pain program comes in multiple forms: an online webinar, a print digest and more than 140 live meetings held in 21 states over the last three years. The training walks physicians through the fictional case of Mary Williams, a 42-year-old mother and recovering alcoholic with hypertension and Type 2 diabetes with painful neuropathy. She tells her new doctor she suffers from a “20 out of 10″ on the pain scale.

The program addresses the science and medicine of opioid prescribing, but also talks about creating empathy between the patient and the doctor.

“There is zero percent risk of believing a patient’s pain complaint 100 percent of the time,” Alford says at one point in the online training. “You believe their pain but now need to decide, using the risk-benefit framework, what is the appropriate therapy.”

Mandated education

physicians prescribing fewer opioids, athenaInsight
Data from the athenahealth network shows that primary care physicians nationwide are prescribing fewer opioids.

SCOPE of Pain and similar programs are partially funded by drug companies themselves. In 2012, the Food and Drug Administration required the manufacturers of extended-release, long-acting opioids to support continuing education on the safe use of the drugs. In March 2013, SCOPE of Pain was the first recipient of the FDA-mandated funding.

Some states have also made opioid-prescription training a requirement for doctors. For the past four years, for instance, Massachusetts has required physicians applying for license renewal to complete at least three credits of education and training in pain management.

That new training can be useful for veteran doctors, Alford says. For years, doctors freely prescribed opioids. But as more people have become addicted and died from opioid overdoses, many physicians have decided that it’s too risky to even pull out the prescription pad.

That can’t be the answer, he says.

“Our training is really trying to look at this whole thing with a balanced perspective,” Alford says. “We are over-prescribing these medications, no question. We need to prescribe less. But let’s base that decision based on the individual patients, not globally.”

Still, Alford understands the pressures doctors, nurses, pharmacists, and other healthcare professionals face every day. As an addiction treatment specialist for more than 20 years, he still faces conflicts in the exam room.

One of his recent patients, who takes opioids for chronic pain, was showing some red flags, such as running out of pills early and not bringing in the medication so the doctor could check that he was taking the prescription slowly enough. So Alford told him he had to taper him off the medication, with the goal of stopping. The patient was not happy. Alford was uncomfortable.

A tense 45 minutes later, the man stormed out of the exam room without a new prescription, slamming the door.

For the rest of the day, Alford was running late with his other patients. He was upset with how the exam had gone. And when he checked his messages at the end of the day, the angry patient had called the office to tell him, “Thank you for ruining my life.”

“The patient was furious, my other patients were furious, and I felt bad for an entire week,” he says. “It would have been a hell of a lot easier for me to have just written the prescription.”

Alford says he hopes SCOPE of Pain, which has issued more than 35,000 certificates to health care providers across the country since May 2013, will help give doctors the tools to prescribe responsibly. A study published in the journal Pain Medicine in January found that immediately after completing the program, 87 percent of participants said they would be making practice changes. Two months later, 67 percent said they felt more confident about prescribing opioids safely.

Strength of opioid prescriptions over time, athenaInsight
Data from the athenahealth network shows that primary care physicians nationwide are prescribing lower dosages of opioids.

Ellie Grossman, M.D., an internist focused on behavioral health at Cambridge Health Alliance, took the training a year ago when she moved to Massachusetts and renewed her medical license. Now, she hopes to use SCOPE of Pain materials to create a shorter training module for the entire organization.

Physician culture around opioid prescribing needs to change, she says, and doctors benefit from mandated continuing education — as well as from feedback from medical directors, headlines about the epidemic, and changes in state law.

“Culture change is hard and it’s slow, no matter how much we like to think otherwise,” says Grossman.

Doctors understand their responsibility in the crisis and want to do the right thing, says James S. Gessner, M.D., president of the Massachusetts Medical Society, which has published its own guidelines and trainings for doctors.

“I haven’t spoken to any physicians who are grumpy about having to learn about opioid prescriptions,” Gessner says. “Physicians are always interested in learning and best practices.”

Allison Manning is a writer based in Boston. Photos courtesy of Boston University School of Medicine.

Bridging the doctor-patient divide over opioids