Figuring out an exit plan for patients stuck on opioids to manage pain

It’s hard to refuse to help a person in pain.

No one knows that better than Kelly Barth, a psychiatrist and internal medicine physician at the Medical University of South Carolina who focuses on the management of patients on opioid medications for chronic pain.

“Patients suffering from chronic pain can have a worse quality of life than patients with cancer. Pain adversely affects their daily life, interpersonal relationships, and robs them of the things they value most. I see patients who are suffering with pain despite having tried many different medications and surgery.”

Chronic pain affects an estimated 100 million people, with related health care costs exceeding $600 million, she said. “In the U.S., which represents about 5 percent of the global population, we consume 80 percent of the world’s prescription opioids.” Most recent guidelines suggest that opioids are ineffective for long-term management of chronic pain.

This has led to very visible issues in the opioid crisis. “Two million people are diagnosed each year with prescription opioid addiction and another 7 million people are stuck on opioids that are no longer working but don’t qualify for addiction treatment,” she said. “This means there are 7 million people in the pipeline at risk for addiction and overdose death.” 

It’s why Barth is thrilled that MUSC has been authorized through the Statewide Health Innovations legislative priority to receive funding through the South Carolina Department of Health and Human Services to support a demonstration project for the state’s first pain rehabilitation program. “MUSC’s Intensive Program for Pain Rehabilitation will be a three-week, intensive outpatient program. Patients will receive daily physical therapy, psychotherapy and medical management, all while tapering completely off their opioid pain medications,” she said.

The program focuses on:

• Helping patients work through their fears of pain and withdrawal 
• Minimizing the burden of excessive co-pays associated with physical therapy and psychotherapy
• Providing a referral option for primary care doctors who may lack time to do non-opioid pain management and opioid tapering

Barth, an advocate for better treatment for chronic pain patients, said it’s one of the most needed programs in the state. “We need a civilized exit plan for those who need to come off chronic opioids so that they can have time to learn different ways to manage their pain, and we’re not abruptly taking people off their pain medications.” 

The state is among those with the highest rates of opioid prescribing in the nation, with the number of opioid prescriptions exceeding the number of residents in 2014, she said.  Most of the chronic pain patients, who consume the majority of opioids in this state, do not qualify for addiction treatment. “They do not have addiction — they are simply stuck on opioids with no exit plan. Most of them express that they would like to come off their medications, but their biggest fears are feeling symptoms of pain and withdrawal.”

Unlike those who have addiction, there are no current systems in place to support these patients in safely tapering off their opioids. The problem was created because the medical system, as it is set up now, favors the use of pills over the more effective, yet more time-consuming treatments for chronic pain such as physical therapy or psychotherapy, she said. 

“There’s a huge need to change the culture of how we treat chronic pain. Although the mantra in our pain program is ‘skills not pills,’ patients will often report they just cannot afford to do the right treatment for their pain, as it is more expensive and time-consuming than simply filling the $4 bottle of pills. The patients feel stuck, and the provider often feels helpless.” 

The irony is that most recent data suggest opioids aren’t effective for chronic pain. “But coming off is not easy, and we need to support patients in getting through that withdrawal and practicing a different way to manage their pain.” Early clinical data shows that most patients who are able come off chronic opioids find their pain does not get worse.  

What they do find instead is a chance for a better quality of life. 

Based on the Mayo Clinic’s pain rehabilitation program, the MUSC program will provide a comprehensive assessment and treatment plan for patients to learn how to live without opioids while decreasing their pain levels to achieve a better quality of life. That also translates to a decrease in health care costs, she said.

“Working with patients to come off chronic opioids can take an appreciable amount of time, time that primary care physicians often don’t have.”

Better exit plans

That’s why it’s helpful to have specialty clinics such as the MUSC Health Women’s Reproductive Behavioral Health Clinic, run by Constance Guille, M.D.

The epidemic of opioid use extends into pregnancy, with anywhere from 15 to 20 percent of pregnant women being prescribed opioids. Guille said that over the past decade, there has been a fourfold increase in the chronic use of opioids during pregnancy, and a twofold increase in opioid use disorder. “We really care about this population. This is a group of women who are coming into pregnancy with chronic pain, and they are having difficulties with their opioid medications and want help.”

The issue poses problems for the moms and their babies. Every 25 minutes, a baby is born going through opioid withdrawal. Treating them cost $1.5 billion in 2012. It continues to be a public health crisis, but the good news is that pregnancy creates an opportunity to intervene. “Pregnancy is this ideal window of opportunity because women are afforded health insurance and they have multiple contacts with the hospital system and they are really invested in positive health behaviors because they want to invest in their children’s futures.”

Guille, a psychiatrist, has developed a program to help women wean off their opioid medications, and it’s been a huge success, with pregnant women reducing prescription opioid use, misuse and abuse by about 75 percent. “We were able to improve maternal functioning and decrease pain, which is really interesting. We are taking these people off pain medications while they are pregnant, which is when pain symptoms can get worse, and they actually are doing a lot better. Their mood and anxiety symptoms improved as well.”

She’s also received funding to extend the program to rural areas through telehealth, she said.

This is exactly what physicians need:  more options, said Kathleen Brady, a psychiatrist and researcher who specializes in addiction at MUSC. She’s working to inform doctors about evidence-based opioid and pain treatments through the SC MAT ACCESS project. SC MAT stands for Medication-Assisted Treatment Academic Community Capacity Expansion for Sustainable Success. 

“There is a lot pain. Pain is the No. 1 reason people go to the doctor. You can’t ignore it, but we need to find better ways to treat it.” 

MUSC researchers are investigating several options.

“We’re looking at neurostimulation treatments to decrease pain. Others in the basic science area are looking at alternative medications to treat pain without the addictive properties,” Brady said. 

MUSC also has a scrambler clinic, which uses a rapidly-changing electrical impulse to send a “non-pain” signal along the same pathway that a person is experiencing a pain stimulus. The clinic has been so popular, there’s a waiting list. There are plans to expand the clinic’s services so outside referrals can be taken at some point.

Brady praises MUSC’s new chronic pain program, opening this fall, for its multi-modal approach. Based on a comprehensive assessment, doctors and nurses will select the best combination of medications, physical therapy and psychotherapy for each patient. “Believe it or not, cognitive behavioral therapies such as ACT or acceptance and commitment therapy,” Brady said, “can be very helpful in helping people manage their pain.”

Barth said the program may expand at some point to offer an “executive weekend” option for those who can’t afford to take time off work. She also hopes this will make it easier for patients to get the help they need to treat their pain, without the stigma that can be associated with addiction treatment.

“Health care professionals in the program don’t see pain patients as addicts,” she said. “These are people seeking treatment for their pain. There’s a misconception – not only in the public, but also in the medical profession, that all patients on chronic opioids have addiction. Most of these patients desire to come off opioids, but they fear pain and they fear withdrawal. We need a humane way to help them."

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What You Should Know About Opioid Use

Dr. Kathleen Brady's top tips for patients: 

• You can take responsibility for your pain management. If you’ve had a procedure that causes pain, you should take opiates as needed. But if you take an opiate daily for three weeks or more, you are going to have some level of physical dependency. 
   
• Ask your doctor about tapering, take opioids only as needed and supplement with other non-opioid type medications.
   
• Opioids are not the best treatment for chronic pain. If the pain turns from acute to chronic, then seek alternative treatments such as electrical stimulation and other medications. Antidepressants, non-steroidals like ibuprofen and anti-seizure medicines can help.
   
• When you are prescribed opiates, treat them with care. Many of the overdoses in kids involve teenagers raiding their family’s medicine cabinets. The drugs should be kept in locked compartments and disposed of properly. Otherwise, you have a recipe for disaster.
   
• Be aware of increases in potency. Fentanyl is probably 10 times as powerful as morphine. Carfentanil, used to tranquilize large animals, is 1,000 times more potent. Carfentanil can kill you in a second, and it’s getting mixed in with other drugs.