The AAFP recently updated its "Chronic Pain Management and Opioid Misuse: A Public Health Concern" position paper to better equip members to combat the opioid abuse epidemic while continuing to treat their patients' chronic pain.
"The intertwined public health issues of opioid abuse and pain management that have touched medicine, media, Hollywood news, small communities and families across our country called for an update to the AAFP's position paper on opioid abuse and pain management," said David O'Gurek, M.D., of Philadelphia, who chaired the AAFP workgroup that oversaw the position paper update.
Furthermore, O'Gurek told AAFP News, "As the AAFP works with multiple partners nationally in addressing the opioid crisis, family physicians have both a huge opportunity as well as a duty to the patients they serve to play a role in the multifaceted solution to the opioid epidemic."
Highlights of the Updated Paper
The updated position paper paints a picture of the current opioid misuse and abuse crisis, including providing historical context on the increase in opioid prescribing seen in recent years.
- The AAFP updated its opioid misuse and pain management position paper to better equip members to combat the opioid abuse epidemic while treating patients' chronic pain.
- The updated paper contains an extensive call to action for Academy members, noting that family physicians can play a key role in providing medication-assisted treatment to patients with substance use disorders.
- Although the paper attempts to provide perspective and resources for family physicians working to balance effective pain management and safe opioid prescribing, it is unable to provide clear evidence-based guidelines or answers.
For example, in 2012, the number of opioid prescriptions written (259 million) equaled the adult population of the United States.
"With primary care physicians prescribing approximately 50 percent of all opioids dispensed, family physicians have certainly fallen under scrutiny in the face of an opioid epidemic with rising numbers of complications, overdoses and death," O'Gurek said. "The competing principles of ensuring adequate pain treatment balanced with appropriate prescribing are certainly highlighted within the paper."
The paper also discusses the new CDC guideline on opioid prescribing for chronic pain,(www.cdc.gov) as well as referencing guidelines and policies from groups such as the Substance Abuse and Mental Health Services Administration, the American Society of Addiction Medicine, and the Federation of State Medical Boards.
"These documents are being referenced nationally on issues related to addressing the opioid crisis and are useful for family physicians to be aware of," O'Gurek said. "Furthermore, they can be utilized to develop workflows and policies within states and health care organizations to deliver better care at the individual and population health levels."
Additionally, the position paper directs members to the AAFP's new opioid and pain management toolkit, which O'Gurek said practices could use to evaluate their current policies regarding pain management and opioid prescribing. "These resources are valuable tools to develop new policies and protocols for practices and health systems," he noted.
Also of note is the fact that the updated paper includes a new section on the family physician's role in caring for patients with opioid use disorders.
"Overdose education and naloxone distribution programs have demonstrated success in curbing overdose rates, and family physicians -- as leaders within their communities -- need to be aware of this," O'Gurek said.
Call to Action for FPs
Overall, said O'Gurek, family physicians are in a unique position to play a critical role in the multifaceted approach needed to address the opioid epidemic.
"Patients struggling with substance use disorders need nonjudgmental, patient-centered as well as family-centered care that utilizes a multidisciplinary approach," he said. "Sadly, the stigma of addiction remains, and the current opioid abuse epidemic has not overturned this."
O'Gurek also pointed out that as family physicians work to develop medical neighborhoods, they should be mindful of the need to include community resources as key components of the multidisciplinary teams necessary to provide the care these patients require.
In addition, O'Gurek said, "While local, state and national governments are evaluating current legislative efforts on opioid prescribing and coverage for patients struggling with substance abuse, family physicians can specifically use the advocacy calls to action to ensure legislative efforts address issues unique to family medicine."
According to O'Gurek, the current national focus on medication-assisted treatment (MAT), particularly for pregnant patients struggling with opioid dependence, may increase the desire for such treatments.
In that case, he added, "Family physicians can play a critical role in the national solution to this epidemic by stepping up to the plate in providing office-based substance abuse care."
O'Gurek said curbing the opioid epidemic must involve a comprehensive approach that focuses on prevention, harm reduction, treatment and reintegration services for those struggling with opioid use disorders.
"Therefore, MAT should not and cannot be viewed as a single approach for confronting the issues we face," he said. "However, it has been a successful strategy for many individuals who seek treatment."
The paper describes how family physicians can receive a waiver to prescribe MAT in their practices and also discusses some of the barriers physicians note for not doing so -- which O'Gurek said policymakers could address to facilitate this aspect of care.
And although several options are available for MAT, buprenorphine is an office-based approach that is well-suited to family physicians, he noted.
"While some studies suggest a slight superiority of methadone to buprenorphine in certain patients, both are highly effective means of treatment of opioid dependence," said O'Gurek. "Furthermore, growing evidence demonstrates the benefits of buprenorphine therapy, particularly for pregnant moms in treating opioid dependence and also significantly reducing NICU stays for neonatal abstinence syndrome."
Lack of Evidence Remains
Although the paper offers perspective and resources for family physicians working to balance effective pain management and safe opioid prescribing, it is unable to provide clear evidence-based guidelines or answers.
"The unfortunate reality is that there is very little evidence to guide and direct physicians with regards to opioid use for chronic pain," O'Gurek said. "Given such a dearth of research, family physicians need a great deal of strong, quality research on chronic pain management that will inform policy and insurance coverage practices to alleviate the challenges and red tape in caring for patients with chronic pain, as well as those with substance use disorders."
Future resources that would be helpful in managing patients with chronic pain would include usable, point-of-care strategies for screening, risk stratification, dose titration and de-escalation of therapy, O'Gurek observed.
"Many family physicians can identify patients for whom they prescribe opioids for chronic pain that have improved functionality, do not demonstrate signs of misuse and remain stable, productive members of society," he said. "The current climate poses a risk that these individuals may no longer receive such pain treatments" and, therefore, may not have their pain treated appropriately.
Finally, O'Gurek pointed out that the updated position paper was the product of the hard work of several family physicians, including Robert "Chuck" Rich Jr., M.D., of Bladenboro, N.C., and Jim Stevermer, M.D., of Fulton, Mo., along with AAFP clinical policies strategist Melanie Bird, Ph.D.
"This quality product lays the groundwork for the AAFP's work moving forward to combat the opioid crisis and draw attention to the needs of the physician community to better serve those struggling with chronic pain and/or substance use disorders," O'Gurek said.
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