Clinicians face two opposing realities in the U.S. today: rampant (and highly publicized) opioid abuse, and epidemic undertreatment of pain for seriously ill patients. How do clinicians ensure safe and effective treatment of pain for seriously ill patients while acknowledging risk for substance use disorder and diversion?

Opioid abuse has become a devastating issue for many Americans, leading to new restrictions and regulations on opioid prescribing for patients with chronic pain: “About 40 Americans die each day from overdosing on prescription painkillers, according to the CDC. In 2013, an estimated 1.9 million people abused or were dependent on prescription opiates.” This serious public health epidemic has spurred proposals largely focused on restricting patient access to opioid analgesics.

  • A recent Business Insider article noted that “as the prescription opioid and heroin crises have reached a fever pitch, federal and state governments have responded with increased restrictions on opioid prescribing, prescription-drug-monitoring programs to track prescriptions, laws implicating doctors whose patients [develop substance use disorder] and more detailed guidelines for prescribing.”
  • On Tuesday, March 15th, the Centers for Disease Control and Prevention (CDC) released its new Guideline for Prescribing Opioids for Chronic Pain which strongly advise against use of opioids for chronic pain, with the exception of cancer patients under active treatment, patients receiving palliative care, and those in hospice care.

But there is another, equally devastating public health crisis going on at the same time- the epidemic of undertreatment of pain.

An important distinction lies in the nature of the patient population with pain (post-operative pain; chronic pain without concurrent serious illness vs. pain associated with serious medical illness). Dr. Andrew Esch, palliative care specialist and CAPC faculty noted that “the current policy proposals, intended to apply to patients with chronic pain without a concurrent serious illness, should not be broadened to restrict access for the large population of patients with significant chronic pain in the context of serious illness.” Overly restrictive policies unintentionally contribute to the undertreatment of disabling pain in people living with serious illnesses (such as cancer, stroke, heart failure, emphysema, end stage renal and liver disease, and frailty), rather than achieving their intended purpose – to protect both patients and providers. “Thoughtful policy proposals can curtail the epidemic of misuse and diversion of opioids while balancing the need to ensure safe and effective analgesia for those with pain associated with serious medical illness.” said Dr. Esch.

Several days after the release of the CDC Guidelines, another branch of government released a balanced message about how to treat the millions of Americans suffering from pain:

  • On Friday, March 18th, the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services released a National Pain Strategy, outlining the federal government’s first coordinated plan for achieving a health care system in which all people receive appropriate, high quality and evidence-based care for pain. The Strategy calls for:
    • A system of integrated pain management practices based on a biopsychosocial model of care and the full spectrum of pain treatment options.
    • Reducing barriers to pain care and improve the quality of pain care for vulnerable, stigmatized and underserved populations.
    • Helping to develop a better informed health care workforce with regard to pain management.

Access to care that appropriately assesses benefits and risks to people suffering from pain in the context of a serious medical illness or illnesses remains a priority that needs to be balanced with efforts to curb inappropriate opioid prescribing and use practices. This can be accomplished by:

  • Improving provider education on pain management practices in persons with serious illness and team-based care using multiple treatment options.
  • Improving patient self-management strategies, as well as patient access to quality, multidisciplinary team care that does not depend solely on prescription medications, especially for vulnerable populations.
  • Encouraging the evaluation of risks and benefits of current pain treatment regimens for those with serious illness.
  • Providing patients and families with educational tools to encourage safer use of prescription opioids and to prevent diversion.

So how do those of us in palliative care interpret these messages and how can we remain true to our commitment to reducing suffering for our seriously ill patients?

The first step is contained in the introductory paragraph of the new CDC Guidelines: know your patient population. While opioids are not recommended for patients with chronic pain in the absence of serious illness, opioids can be part of a safe and effective treatment plan for the palliative care population of seriously ill patients. The following section of the introduction specifies that they are not intended to restrict prescribing for the palliative care patient population:

“This guideline is intended to apply to patients aged ≥18 years with chronic pain outside of palliative and end-of-life care. For this guideline, palliative care is defined in a manner consistent with that of the Institute of Medicine as care that provides relief from pain and other symptoms, supports quality of life, and is focused on patients with serious advanced illness. Palliative care can begin early in the course of treatment for any serious illness that requires excellent management of pain or other distressing symptoms (35). End-of-life care is defined as care for persons with a terminal illness or at high risk for dying in the near future in hospice care, hospitals, long-term care settings, or at home. Patients within the scope of this guideline include cancer survivors with chronic pain who have completed cancer treatment, are in clinical remission, and are under cancer surveillance only. The guideline is not intended for patients undergoing active cancer treatment, palliative care, or end-of-life care because of the unique therapeutic goals, ethical considerations, opportunities for medical supervision, and balance of risks and benefits with opioid therapy in such care.”

Step two: Ensure that everyone on your team and in your organization is trained in pain management during a serious illness, including safe opioid prescribing. This training must cover how to adhere to Federation of State Medical Boards Guidelines for safe and effective pain management using the full range of approaches; if, when, and how to safely prescribe opioids and manage their side effects; how to screen for substance use disorder risk; how to manage pain in patients either at-risk for or who have concurrent substance use disorder; and how to monitor for and prevent diversion. It is the responsibility of the provider to recognize and safely manage pain to reduce its impact on function and at the same time to prevent misuse, diversion, injury and death. There is a balance between mitigation of risk and management of pain, and training is required to achieve this balance.

It is the responsibility of the provider to recognize and safely manage pain to reduce its impact on function and at the same time to prevent misuse, diversion, injury and death.

Unfortunately, the pain management training required to achieve this balance is inadequate in medical and nursing education. In most medical schools, students receive only a few hours at most of education on pain. Appropriate education on safe prescribing and managing pain practices, especially in the context of risk for substance use disorder, can help address the epidemic of prescription-opioid misuse.

CAPC Resources Can Help

Available to all staff at member organizations, CAPC’s online curriculum in pain management provides training in the knowledge and skills needed to safely and effectively manage pain for seriously ill patients (in alignment with the Federation of State Medical Boards Guidelines). The courses are designed to be easy to access and easy to use (important for busy clinicians) and provide free continuing education credits for physicians, physician assistants, nurses, social workers, case managers and licensed professional counselors. Whether mandated or encouraged, CAPC courses are one strategy that can be used to close gaps in pain management training for new or mid-career clinicians.

Other resources for training clinicians on pain management for palliative care patients include ELNEC, EPEC, and the American Academy of Pain Medicine.

Take CAPC's course, Converting from Short-Acting to Long-Acting Opioids, which focuses on patients with persistent pain as it takes learners through the process of converting from short-acting to long-acting opioids.