Opioid prescribing for chronic pain—achieving the right balance through education
In recent decades, the United States has seen a dramatic increase in opioid prescribing for chronic pain. That growth has been associated with increasing misuse of these medications, leading to alarming increases in unintentional opioid overdose deaths.
In a perspective in this week's New England Journal of Medicine, Daniel Alford, MD, MPH, associate professor of medicine and assistant dean of Continuing Medical Education and director of the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) program at Boston University School of Medicine (BUSM), recommends that prescriber education is the best approach to addressing the prescription opioid-misuse epidemic, allowing for individualized care on the basis of a patient's needs after a careful benefit-risk assessment.
According to Alford, a key problem is that clinician education around pain management and safe opioid prescribing has been lacking. As opposed to blunt regulatory solutions that decrease access to opioids in an indiscriminant way, education is a more finely tuned approach that can empower clinicians to make appropriate, well-informed treatment decisions for every patient at each clinical encounter. "Education has the potential to both reduce overprescribing and ensure that patients in need retain access to opioids," explained Alford, who is also medical director of Boston Medical Center's Office-based Opioid Treatment (OBOT) program.
Alford points out clinicians have limited tools at their disposal to help patients with severe chronic pain and the reimbursement system favors the use of medications alone, despite evidence supporting multimodal pain management. Moreover, whereas clinicians can use objective measures to guide their management of other chronic diseases, here they must rely solely on the patient's (or family's) reports of benefits (such as improved function) and harms (such as loss of control).
Alford believes voluntary prescriber education may be insufficient to address this problem and that mandatory education may be required. "If so, it will be important to link mandated education to medical licensure to avoid having clinicians opt out—since that could lead to reduced treatment access, as well as burnout among the clinicians who opt in," he added.
Alford believes that the medical profession is compassionate enough and bright enough to learn how to prescribe opioids, when they are indicated, in ways that maximize benefit and minimize harm. "Though managing chronic pain is complicated and time consuming and carries risk, we owe it to our patients to ensure access to comprehensive pain management, including the medically appropriate use of opioids."