Key Points for Practice
• Physicians should provide patient-centered care, including coordinating with other disciplines, to patients with chronic pain or dependence on opioids.
• Practices should encourage their physicians to use medication-assisted treatment options for patients with opioid dependence.
• Physicians are encouraged to use their state prescription drug monitoring programs for tracking purposes, to identify abuse or diversion, and recognize persons who might be at risk.
• Methadone, buprenorphine, and naltrexone are used as opioid substitutes in medication-assisted treatment.
From the AFP Editors
Managing chronic pain and opioid misuse can be challenging. Although data on the risks of opioid use have become clearer, knowledge of the long-term benefits is limited. Overprescribing, misuse, diversion, and dependence have occurred as a result of external pressures, physician behavior, inadequate evidence, and pharmacologic development. Family physicians could play an important role in alleviating these problems; therefore, the American Academy of Family Physicians (AAFP) is committed to ensuring family physicians are a part of the solution.
Call to Action
The AAFP formed an advisory committee to focus on the issues involved in addressing undertreated pain and opioid misuse at a variety of levels, and is calling for action from itself and its members.
Physicians should provide patient-centered care to those with chronic pain or dependence on opioids, and should work with other health care professionals to provide multidisciplinary care. Evidence and guidelines regarding management of chronic pain and opioid dependence should be assessed. It is important to recognize risk factors for overdose or misuse in persons with chronic pain taking opioids, and to properly use prescription drug monitoring programs, drug screening, treatment agreements, or other methods to counter these factors. Obtaining a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver should be considered to provide opioid treatment in the office. Persons at highest risk of overdose should be given information about antidotes, such as naloxone, as well as provided access.
In addition to physicians, there are opportunities to help at the practice, community, education, and advocacy levels. For practices, avoiding judgment and being knowledgeable about and sensitive to different cultures is important, as is researching practice patterns and procedures, and working with other research networks to build a knowledge base for patient care, especially higher-risk populations. Practices should encourage their physicians to use medication-assisted treatment options for patients with opioid dependence.
For communities, connecting with local medical organizations and offices will help ensure that patients with chronic pain or opioid dependence are provided with appropriate treatment, and working with organizations and patient advocacy groups in the community will assist with resolving problems and destigmatization. Facilitating the creation of education programs and naloxone distribution programs is also important.
On the education level, residency programs can be aligned and continuing medical education can be expanded to provide evidence-based information on best practices and opportunities for DATA 2000 waiver training.
On the advocacy level, payment models and insurance coverage can be adapted to allow physicians to provide appropriate care including coverage for medication-assisted treatment. Where needed, greater accessibility to naloxone should be supported and Good Samaritan protections provided for prescribers and laypersons who are rescuers. Partnering with other state and national groups can help improve monitoring programs and create best practices for their use, and support for research can be expanded, with specific focus on populations at higher risk.
Role of Family Medicine
No methods for evaluating risk have been validated in a variety of locations or patient populations, and common risk factors (e.g., psychological problems) can result in discrimination toward higher-risk populations. Physicians are encouraged to use their state prescription drug monitoring programs for tracking purposes, to identify abuse or diversion, and to recognize persons who might be at risk.
Knowledge of how naloxone works as a reversal agent in opioid overdose is important for reducing harm. Most data about naloxone are not of high quality; however, studies have routinely shown naloxone to be of benefit, and it is the standard treatment option for emergency medical service and emergency department personnel when treating opioid overdose. Physicians are encouraged to provide naloxone to patients at high risk of overdose. In the past 20 years, a substantial number of opioid reversals by laypersons have occurred, which are often the result of education and naloxone distribution programs.
Methadone, buprenorphine, and naltrexone (Revia, Vivitrol) are used as opioid substitutes in medication-assisted treatment. Adjunctive drugs (e.g., clonidine, nonsteroidal anti-inflammatory drugs) are appropriate for some symptoms of withdrawal. With DATA 2000, physicians meeting certain criteria can get a waiver to prescribe office-based opioid therapy with buprenorphine. The criteria include state licensure, Drug Enforcement Administration registration to provide Schedule III, IV, or V medications, completion of an online or live training course to manage opioid use disorder, and submitting documentation to the Substance Abuse and Mental Health Services Administration. Residents in training can also obtain a waiver if they have the proper license and Drug Enforcement Administration registration.
Only about 4% of family physicians have a DATA 2000 waiver. Although there are obstacles to getting a waiver and providing treatment in the office, this is a large opportunity for family physicians and, therefore, the AAFP encourages obtaining the waiver and implementing medication-assisted treatment.
Federal and state agencies, as well as professional organizations, have developed guidelines to assist with managing opioid use disorders. More information about these guidelines can be found in the full AAFP position paper. The AAFP also has a policy on substance abuse and addiction at https://www.aafp.org/about/policies/all/substance-abuse.html, and provides a chronic pain management toolkit at https://www.aafp.org/patient-care/public-health/pain-opioids/cpm-toolkit.mem.html.
Guideline source: American Academy of Family Physicians
Evidence rating system used? No
Literature search described? No
Guideline developed by participants without relevant financial ties to industry? Not reported