Barriers to opioid monitoring in primary care

Barriers to Opioid Monitoring in Primary Care

Erin E. Krebs, MD, MPHMinneapolis VA Health Care SystemUniversity of Minnesota Medical School

Disclosures I have no financial relationships that may

pose a conflict of interest to disclose I will not discuss off-label use of drugs,

biologics or medical devices My work is supported by the VA. The views

in this presentation are mine and do not necessarily reflect the position or policy of the VA or the US government

Outline Background—goals and current practice Specific barriers Implications for practice

Opioid monitoring Ongoing assessment of benefits/harms of

treatment and adherence to therapy Primary goal is patient centered – to maximize

benefit, minimize harm for individual patient Secondary goal is for public health – to minimize

potential harm to others Tools: regularly scheduled visits, history-

taking, care plans, outcome measures, drug testing, pill counts, prescription drug monitoring programs, tracking/documentation of aberrant behaviors

Balancing benefits and harms

Pain relief

Abuse/ addiction

Balancing benefits and harms

Uncertain risks

Uncertain benefits

Abuse/ addiction

Social role

Work

Pain relief

Tolerance

Dependence

Sleep disordersPain hyper-

sensitivity

Hypogonadism

Injuries

SymptomsMood

Physical activity

Limitations of monitoring “Although evidence is limited, the expert

panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain.”

Chou et al., Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain 2009;10(2):113-130


panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain.” Most evidence for benefits of opioid monitoring

strategies is low quality or indirect



panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain.” Most evidence for benefits of opioid monitoring

strategies is low quality or indirect Monitoring doesn’t correct for lack of careful

patient selection Doesn’t address underlying deficiencies in

pain management training and services


Opioid monitoring in practice Studies show low use of opioid monitoring Evidence of risk stratification is mixed

High risk patients receive more recommended practices Urine drug testing Mental health visits Documentation of adherence assessment

But high risk patients also receive more high risk practices Early refills High opioid doses Concurrent benzodiazepines

Krebs EK, Pain Med 2011;12: 740–746; Morasco BJ, J Gen Intern Med 2011;26:965–71; Seal KH, JAMA. 2012;307(9):940-947; Starrels JL, J Gen Intern Med 2011; 26(9):958–64

Opioid monitoring in practice Primary care providers rarely follow

recommendations for monitoring of opioid effectiveness, harms, and adherence

Why?

“The biggest problem in the whole thing is lack of time. Typically these are complex people with multiple problems, and you really could spend the whole appointment, more than one whole appointment just talking about this. We have all these reminders that we have to do, and all the scripts, and they’re wanting a podiatry consult, and an eye consult, and you just have to really sit down and go through a person’s record, and try to make a rational decision. It’s a horrible time problem. But I take it very seriously... What if you do create an opiate problem for somebody?”

Structure of primary care practice Short appointment times (15-20 minutes) Infrequent visits Heavy burden of non-reimbursed tasks Competing demands

Complexity of visits and number of clinical tasks per visit increasing faster than visit duration

Estimated time to accomplish all recommended preventive services: 7.4 hours/day One study found patients on chronic opioids

received fewer cancer screenings

Abbo ED, J Gen Intern Med 23(12):2058–65; Buckley DI, Ann Fam Med 2010;8:237-244. Chen MA, J Gen Intern Med 2010;26:58–63; Dyrbye LN, Arch Intern Med epub 2012; Yarnall

KS, Am J Public Health 2003;93:635–641

“For those patients that have a legitimate reason for wanting to take it and if I can trust them—that they are not selling, they’re not abusing—and most of these are older patients of mine, I don’t have them sign a contract because they never request early refills, they don’t go to the ER in between visits to get them, and so there’s no need for me to do periodic drug screenings and so forth.”

Confidence in risk perceptions Many physicians do not monitor adherence when

patients are perceived as low risk Commonly cited factors: older age, verifiable source of

pain, absence of red flags, “gestalt” Research does not support this selective monitoring

Neither patient report nor physician impression accurately identifies illicit substance use

Physicians do not accurately perceive opioid misuse Presence of aberrant behaviors does not discriminate

between patients with and without rx drug use disorder Good news : Many patients support universal

monitoring, often based on personal experiences and concerns

Fishbain DA, Clin J Pain 1999; 15:184-91; Fleming MF, J Pain, 2007;8:573-82; Melzer EC, Pain Med epub 2012; Vijayaraghavan M, J Gen Intern Med 2011;26:412–8.

“I think it’s destructive to a basic patient-doctor relationship. You’re there to help them and they can tell you their deepest, darkest secrets, but yet you’re policing them.”

Negative attitudes about monitoring Many physicians described opioid

monitoring as being more like policing than doctoring Focus on trustworthiness of patient Conflict with patient-centered care

Good news: Most patients did not view opioid monitoring this way Patients viewed opioids as dangerous drugs

(causing addiction, interacting with other substances)

Patients wanted physicians to focus on their safety

“I usually don't have to ask them if their pain is under good control. Most of them will come to me with their concerns.”

A quick poll Please take a moment to think of the last

patient for whom you wrote an opioid renewal prescription…

How confident are you the patient is experiencing substantial benefit that is clearly outweighing adverse effects?

Highly confident Somewhat confident Not at all confident

Assumption of effectiveness Several patients, but no physicians,

mentioned lack of effectiveness as a reason to discontinue opioids Discontinuations/tapers were initiated by

patients Some patients continued opioids without

benefit Reasons: doctor’s advice, belief they would be

worse off without it (supported by experience with brief withdrawals), belief that higher dose/stronger medicine was needed

Assessing benefit is harder than it sounds, but is the most important task of opioid monitoring In the absence of benefit, no risk is acceptable

Cycle of ineffective opioid use

Persistent pain/distre

ss

Unmet expectatio

ns+/- physical

dependence

Help-seeking

Opioid

Physician response

Interrupting the cycle

Persistent pain/distre

ss

Unmet expectatio

ns+/- physical

dependence

Help-seeking

Opioid

Physician response

Implications for practice Assumption of effectiveness

Patients starting opioids See principles

Patients on established long-term opioid therapy Ask about pain, invest time in listening Assess opioid expectations, concerns, and

experiences Provide education on evolving opioid evidence Address readiness for change at each visit

Implications for practice Negative attitudes about monitoring

Maintain focus on benefits and harms of medication, rather than trustworthiness of patient

Consider broad differential diagnosis for aberrant behaviors

Read and recommend:

Nicolaidis C. Pain Med 2011; 12: 890–897

Implications for practice Confidence in risk perceptions

Train entire care team about harms Educate patients about harms Make it easier to do the right thing (see below)

Structure of primary care Develop systems Institute clinic and facility-level protocols

Thank you!

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Barriers to opioid monitoring in primary care

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