PAINWeek 2017: Advice for Clinicians Dealing With Opioid Prescribing Constraints

Dr Zacharoff provided advice for clinicians dealing with fluid guidelines and constraints regarding opioid prescribing.
The following article features coverage from PAINWeek 2017 in Las Vegas, Nevada. Click here to read more of Clinical Pain Advisor‘s conference coverage.

LAS VEGAS – The keynote lecture at PAINWeek 2017, held September 5-9, was introduced by Stephen J. Ziegler, PhD, JD, associate professor of public policy at Purdue University in Fort Wayne, Indiana, and co-presented with Kevin L. Zacharoff, MD, faculty clinical instructor at SUNY Stony Brook School of Medicine, Department of Preventive Medicine, in New York, who provided advice for clinicians dealing with fluid guidelines and constraints regarding opioid prescribing.1

“The inconvenient truth about the public health problem of opioid addiction and overdose fatalities is that the causes are many, the remedies are complicated, and the legitimate needs of patients in pain are too often ignored,” said Michael R. Clark, MD, MPH, vice-chair for clinical affairs at Johns Hopkins University School of Medicine, Baltimore, Maryland, as he introduced the keynote lecture speakers. Neither emergency declarations, drug-maker lawsuits, “prescriber harassment,” nor patient stigmatization bring any value in resolving the opioid epidemic, he added.

Dr Ziegler then took the stage, denouncing current practices that he equated to “opioid McCarthyism,” in which health care practitioners are “told to fear opioids – all opioids.”  He added: “In such a climate, everyone seems vulnerable to some level of persecution. Practitioners who are prescribing, patients for seeking relief, and people struggling with addiction.” He added: “We have government investigation of the pharmaceutical industry and of prescribers, allegations of conflict of interest for anyone receiving any industry support, and marginalization of people with pain.”

The Centers for Disease Control and Prevention’s guideline for prescribing opioids for chronic pain recommends opting for non-pharmacologic therapies or non-opioid pharmacologic therapies over opioids for chronic pain, thus “ignor[ing] the reality that there are few alternatives that are as effective, or covered by reimbursement,” according to Dr Ziegler.2 “Denial of coverage is denial of care,” he added. He also pointed to the insufficient funding dedicated to pain research or to the development of pain treatments.

Dr Zacharoff offered his perspective as a pain physician: “I am a zealot – I have been a zealot…it’s all about the patient at the end of the day.” The ever-changing guidelines and constraints regarding opioid prescribing create a challenge for clinicians. The process for healthcare providers includes making an assessment of patients, issuing a diagnosis, evaluating risks (eg, adverse effects), communicating with patients, and getting informed consent.

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These considerations are addressed in what Dr Zacharoff deems to be a most important document, the “Universal precautions approach to managing patients with chronic pain and chronic opioid therapy.”3 The processes of consideration, deliberation, justification, and of documentation also require attention. For the consideration process, an understanding of the fact that pain is unlike other medical conditions is critical, said Dr Zacharoff, adding that “pain is one of the few medical conditions where a patient gets to have a say in what a successful treatment outcome is.”

From the deliberation perspective, “it is necessary to think long and hard about what we do,” continued Dr Zacharoff, especially when opioids are part of the treatment plan. Justification requires willingness, effort, knowledge, thought, and persistence. All of the above-mentioned processes need to be documented in the medical record.

“I always thought that the dialogue between the patient and the healthcare provider was between us – private,” he continued. “In today’s environment, that is not the case. There are other forces at play.” Regulators’ and clinicians’ role in the opioid epidemic need to be considered. “I have been and I still am a zealot,” he repeated, to close his talk.

Read more of Clinical Pain Advisor‘s coverage of PAINWeek 2017 by visiting the conference page.

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  1. Zacharoff KL. I have been a zealot (and still am one). Presented at: PainWeek 2017. Las Vegas, NV; September 5-9, 2017.
  2. Centers for disease control and prevention public health service u s department of health and human services. Guideline for prescribing opioids for chronic painJ Pain Palliat Care Pharmacother. 2016;30(2):138-140.
  3. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-112.
Read more of Clinical Pain Advisor‘s coverage of PAINWeek 2017 by visiting the conference page.
Read more of Clinical Pain Advisor‘s coverage of PAINWeek 2017 by visiting the conference page.