In recent years, the treatment of chronic pain has become tricky for providers. While doctors want to ensure their patients suffering from chronic pain get the proper medicine, they must also ensure that at-risk patients do not end up abusing the pain medications. In weighing these tough decisions, doctors constantly struggle to agree on dosages, frequencies and whether to treat a specific patient with pain medication at all. Recently, Vermont providers have had the opportunity to learn more about chronic pain management and how best to prescribe medications for their patients.

Dr. Carlos Pino, an assistant professor at the University of Vermont’s College of Medicine and the medical director of the Center for Pain Medicine at Fletcher Allen Health Care, was one of two speakers at a symposium last December, co-sponsored by UVM and Blue Cross and Blue Shield of Vermont. He aimed to educate the attendees in the dangers and best practices of opioid use in non-cancer pain.

Chronic pain affects 116 million American adults, and costs $635 billion per year in medical treatment and lost productivity. Opioid treatment is one option physicians offer their patients for relief of this chronic pain, but solutions can sometimes bring about more problems. The abuse of opioids, or synthetic narcotics, is a widespread problem in Vermont. According to local experts, doctors need more help in combating abuse. Through further education and understanding, they can continue to reduce and defeat the misuse of these drugs.

“Chronic pain and substance abuse are two different things,” said Dr. Pino. “With information, we will all be more cognizant of what the issues are.”

The half-day seminar focused on the management of opioids for both chronic pain and palliative care. BCBSVT helped develop the talk as a way of meeting Vermont’s new Continuing Medical Education requirements for palliative care and prescribing controlled substances. Sixty doctors and nurses from around the state attended the conference.

The number of people treated for narcotic abuse has only gone up in Vermont since the early 2000s. As Pino pointed out, more than half of the patients seeking treatment of narcotic dependency have coexisting psychiatric conditions like depression, post-traumatic stress disorder and others.

“For patients with chronic pain for five or 10 years, there will be underlying depression,” noted Pino in an interview conducted after the symposium.

History plays a part here. Twenty-five years ago, opioid treatment was for cancer pain only. “Now it’s a standard of care to treat chronic pain with opioids. Physicians can be sanctioned for the under-treatment of pain,” said Pino.

He discussed risk factors like borrowing medications from family and friends, and pointed out that drug overdose death rates have more than tripled in the U.S. since 1990. Dr. Pino stressed that if a patient is high risk, it does not cut out the possibility of opioid treatment. A trial of six to eight weeks is a viable option. “They should just be watched more carefully,” he said.

The Centers for Disease Control has many recommendations on abuse in the treatment of non-cancer pain. Prescription drug monitoring programs, pharmacists requesting identification and increasing the availability of substance abuse treatment programs are among the recommendations. “If people are doctor shopping, you’ll see that patients are going to multiple subscribers,” said Pino.

As for national strategy, he stressed more education of health care providers, patients and families. Prescription drug take-back events also ensure proper disposal, and therefore prevent future abuse.

Opioid abuse isn’t just prominent in the treatment of chronic pain. It also exists in the treatment of cancer pain. Dr. Ursula McVeigh, another assistant professor at UVM’s College of Medicine, was the second speaker at the symposium. The interim medical director of Palliative Care Medicine at Fletcher Allen emphasized education on the use of narcotics for dyspnea, or difficulty breathing, in advanced disease.

McVeigh spoke about applying national guidelines as safe and effective methods for escalating the use of narcotics for uncontrolled pain and dyspnea. She discussed the costs and drug choices related to kidney and liver failure, the finding of a proper dosage and the management of side effects. Drowsiness, respiratory depression, nausea and constipation all constitute possible side effects from the use of these drugs.

One of McVeigh’s key points was the risk involved in prescribing opioids for cancer pain. For patients and families, it’s a big deal choosing whether to accept the risks when they see the signs of serious side effects.

The controversies over the use of narcotics for dyspnea include concerns for respiratory depression and their use at “end of life” when patients are resisting.

Across the board, the symposium surpassed expectations for the majority of attendees. If BCBSVT and UVM hold a similar meeting in the future, most participants said they would attend. When asked what changes they will incorporate after the symposium, one attendee noted plans to use cognitive behavioral therapy for pain management. Another will institute a formal screen for abuse risk, while another vowed to increase the patient education to clients using narcotics.

By no means is the battle against this type of abuse over. Dr. Pino emphasized that doctors are only beginning to realize how to fight it. “Nobody’s done an excellent job figuring out what works or what doesn’t,” he said. “There’s no Magic 8 Ball to figure this out.”

(This article was originally published in the spring issue of Blue Cross and Blue Shield of Vermont’s provider newsletter, FinePoints.)