It starts innocently enough. Perhaps a sports injury, an accident, surgery, or a work-related incident. The physician prescribes pain medication, and for the majority of people, it ends there. The patient takes it as needed and discontinues it when they get better.
But for those with a genetic predisposition for substance use disorders (SUD), stopping may not be an option. They can’t. And thus begins a dangerous descent down the slippery slope of prescription pain medication misuse. Worse yet, because of the cost and difficulty in acquiring pills, some may turn to street drugs, which can increase the risk of overdose.
With all the recent federal and state laws restricting the prescribing and dispensing of controlled substances, it’s clear we have an epidemic of overprescribing. And while physicians certainly don’t intend to get their patients hooked on pain pills, it can be difficult to know who is at risk of a developing a SUD and who is not. In their attempt to help patients, physicians may unknowingly lead them down the path toward the life-altering disease of addiction. Because addiction doesn’t discriminate, you can’t identify a potential SUD risk based on how someone looks, their job, how much money they make, or their lifestyle.
To lower that risk, here are six ways to treat pain while helping patients avoid addiction to prescription pain killers.
Inquire about the patient’s history. Before prescribing any medication, ask the patient about any previous drug misuse, and whether they have a family history of addiction, mental health issues, or substance abuse of any kind. Even if the patient themselves has never had an issue with drugs or alcohol, simply growing up in a home with family members who did creates significant risk. However, be aware that one in five patients admit to lying to their doctor about their alcohol consumption, men more so than women. That means, while you should always ask, you can’t rely entirely on patients to self-report.
Look for red flags. While you generally can’t spot a potential SUD risk through appearance, there are some red flag behaviors that should make providers take pause before prescribing opioids. Be wary of patients who immediately declare they “can’t take” any other drugs and can only take a specific one. While sensitivities and allergies are certainly real, they can also be used to dupe an unsuspecting provider into prescribing a patient’s drug of choice. Other red flags include requesting a refill of an existing prescription on a first visit or dismissing any discussion of other treatment options. Presenting with a diagnosis that’s difficult to validate with labs, imaging, or other tests — or refusing to do the workup required to arrive at a diagnosis — can also be a warning sign.
Set appropriate expectations. Living with chronic pain can be horrible and I’ve known patients who, left untreated, took their own life because they couldn’t bear the pain any longer. As a physician, you certainly don’t want to dismiss or downplay bona fide pain, but it’s important to set reasonable expectations with patients. Pain medications are not intended to totally eradicate pain — they are used to minimize it and improve quality of life. Trying to eliminate pain entirely puts patients at severe risk of dependency and adverse reactions.
Use alternative therapies. Opioid pain meds are far from the only option for treating acute or chronic pain, and physicians should look to alternative therapies before turning to opioids. Non-narcotic medications like NSAIDs and topical pain patches are a great option, along with more invasive treatments like “nerve blocks” or injections at the site of acute pain. Osteopathy, chiropractic, physical therapy, and water therapy are also beneficial, along with acupuncture and therapeutic massage. Meditation and cognitive behavioral therapy can help patients cope with pain and improve quality of life, especially when used in conjunction with other treatment.
Refer to pain management. The treatment of chronic pain has become a specialty with its own fellowship training and specific licensure. Pain clinics are highly regulated in most states, and they follow best-practice protocols that ensure patients receive the appropriate treatment for their particular pain while setting strict boundaries and expectations. This includes policies such as patient contracts, routine checks of controlled substance prescribing databases, and random drug screening to ensure patients are using medications as prescribed. Unfortunately, most community health providers are not equipped to handle chronic pain management, so referring a patient to a pain management clinic early is often the best course of action.
Use the SBIRT protocol. While most community-based health facilities — and I include emergency departments here — are typically not well-equipped to manage substance abuse or chronic pain, they can play an important role in identifying people at risk. The Screening, Brief Intervention, and Referral to Treatment (SBIRT) protocol was developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) to help primary care providers, clinics, and community health centers identify and implement early intervention for at-risk individuals. By providing a universal screening tool to help assess for substance use and risk, SBIRT enables providers to identify at-risk patients and refer them to treatment before substance use becomes an issue. SBIRT is easy to use and should be implemented in every community health setting as part of any routine visit or emergency encounter.
With the number of drug overdoses reaching an all-time high over the last year, medical providers have a responsibility and an opportunity to help reduce the prevalence and risk of one of the biggest public health crises of our time — the opioid epidemic. By taking simple, yet effective steps to identify at-risk patients and implement other means of treatment for both chronic and acute pain, we can turn the tide of opioid addiction and prevent countless deaths, all while ensuring patients get the pain relief they need to live productive, healthy lives.
Mark Calarco, DO, MBA, served as the national medical director for American Addiction Centers from 2013 to 2018. He is currently the CEO of Addiction Labs, which conducts medical and laboratory research and develops innovative products and services aimed at improving patient outcomes.