Perfecting the Delicate Art of Appropriate Opioid Management
For primary care providers, this is a challenging time to be managing patients with chronic pain and substance use disorders. Fraught with stigma and gray area on the best of days, these conditions have become even more charged in the context of the ongoing opioid epidemic. Heightened scrutiny of opioids and tighter restrictions on prescribing have complicated the treatment of chronic pain, while the sheer scope of the epidemic has exposed more providers than ever before to cases of opioid misuse and full-blown opioid use disorder (OUD).
A new state-funded phone consultation service, known as MCSTAP, was launched in Massachusetts in early 2019 to help primary care providers navigate tricky questions regarding addiction and chronic pain. Staffed by a team of physicians with addiction expertise, the MCSTAP hotline offers real-time guidance and a vetted database of referral resources to overwhelmed and ambivalent physicians and nurse practitioners.
Christopher Shanahan, MD, the medical director of MCSTAP, hired the team of physician consultants and brings more than 30 years of experience in medical education and addiction treatment to his role. A primary care physician at Boston Medical Center and an assistant professor at the Boston University School of Medicine, Shanahan has played key roles in a number of innovative clinical programs and is a national lecturer for SCOPE of Pain, a continuing medical education (CME) program dedicated to safe opioid prescribing.
Shanahan and team are continuing to expand the MCSTAP service and are sharing their hard-won experience with primary care providers across the state. HealthCity sat down with Shanahan to understand the complexities of treating people with chronic pain and addiction — and how he walks others through them.
HealthCity: Why is there a need for a hotline such as MCSTAP?
Christopher Shanahan: It's very hard being a primary care doc. You don't have any time. There's usually eight things going on at once with a patient. If you had all the time in the world you could figure it out, but sometimes you're kind of stuck. You have a feeling — I should or shouldn't be doing this, but I'm not sure — and you need to talk to somebody. And that's where a hotline comes in.
If you take some CME courses or read up, you get things in generalities. A case is presented, and you might learn something specific about the case, but what you remember is the general principle.
MCSTAP is very patient-specific. It's this patient. It's this person, with this past medical history, who has these urine drug screening results, who has this diagnosis of pain — or substance use disorder, or even both — and who happens to be with you, asking for this specific thing or complaining of this specific issue. It's a unique algorithm or equation, and MCSTAP takes all of that in context and helps you with your patient. And if you use it regularly, my hope is that you'll start to gain a broader experience. You'll start to connect the dots.
HC: MCSTAP has been up and running for several months. Are you seeing any common themes in the questions the consultants have received?
CS: People are looking for help with some specific things. Tapering is one. For example, if somebody's on a very high dose of opioids, is it appropriate to taper, or not? What do you do with an unexpected urine drug screen? How do you get people started on buprenorphine or naltrexone? How do you manage aberrant behaviors like patients borrowing medicines or giving medicines away, asking for refills early, losing the medicines, not taking medicines as prescribed, yelling at the staff? There's a whole bunch of crazy things that can happen.
HC: How do you handle challenges like that?
CS: What I espouse to my team, and when I go out and teach, is those are all symptoms. We don't know what they mean without gathering more data. They could mean the patient has a use disorder or is diverting meds. They could also mean there's untreated pain, or there's a psychiatric illness that's gotten worse.
We try to be objective and just take all the behaviors as they are. Everybody has a bad day, but when we start seeing the same behaviors over and over again, we take a look at that and try to figure out what's going on. And that may require a higher level of monitoring.
Sometimes it's just a matter of telling the patient, "If you continue to do this, I may be limited in how much medicine I can give you. I may have to stop giving you medicine or I may give a shorter prescription, and you'll have to come here more frequently." Often, just a little tug in the coattail is all it takes to keep the patient engaged in care. When people leave care, bad things can happen fast.
HC: What's the confidence level of the average primary care physician in having those conversations?
CS: I think it's pretty low. They often need more guidance. Many are avoiding opioids now when it would be appropriate to start them cautiously, and they're trying to get people off opioids, sometimes inappropriately — either too fast, too much, or altogether, which isn't always necessary.
I took a call for MCSTAP yesterday about a patient with chronic pain who was on high doses of opioids and had some abnormalities. He'd lose his meds, he'd run out of his meds. There was a certain level of chaos. And the doc came to me, saying, "What do I do here? This is too much. I'm done."
Those are the subtleties of treating people with chronic pain and substance use disorder. The ability to wade out into those hairy areas and still feel you have control takes years to learn. It really does.
By coaching him and counseling him, I helped him realize that he didn't really know what's going on. The pain medicine seemed to help the patient. It didn't sound like he was diverting. He'd never had a positive urine drug screen. I told him, "You don't really have an OUD diagnosis. But there are things you can do to tighten up his care, so that it's safer. You can continue him in care and watch him very, very closely, and look for any signs that something might be going on. By increasing monitoring, you send a strong message that you care and will support him."
Those are the subtleties of treating people with chronic pain and substance use disorder. The ability to wade out into those hairy areas and still feel you have control takes years to learn. It really does. You have to ask people to help you, learn how to do it, and experience it and feel confident in doing it.
HC: Why do so many providers lack confidence in this area?
CS: Until recently, education and training in pain and substance use disorder have been relatively nonexistent and not evidence-based. Even now, they're not even close to adequate.
Substance use disorder and chronic pain are also stigmatized conditions. Because of the stigma and the lack of clinical training, it's easy for clinicians to feel a general uneasiness with these topics. The conversation around them becomes loaded, difficult, and uncomfortable, and often there's a concern that the patient isn't telling you exactly what's going on.
Clinicians who are stressed because of lack of time — and everything else that goes along with clinical work — often avoid these conversations or just abruptly make decisions to taper or stop meds.
HC: How do you help providers work through these situations?
CS: The main thing to remember is that you're still in charge of the medical plan. If you're being asked to do something that's not reasonable, you don't have to feel like you're being coerced. You wouldn't feel that way if the patient was demanding an antihypertensive they didn’t need — "You must give me metoprolol, I have to have metoprolol." You'd have no trouble looking at them and saying, "Sorry, that's the wrong medicine. I wouldn't do that."
But if it's an opioid, all of a sudden you don't know what to say. They might have pain, they might not have pain. It becomes a big deal. You just have to say to yourself, and often to the patient, "This is not the safe thing to do. This is how I practice. I'm going to do only what's good for you." Then you start to forget about stigma, and you forget about manipulation, and all you remember is, "I want to keep you safe."
All of a sudden, I'm caring about the patient again, instead of feeling like I'm against the patient or like they're trying to get me to do something that I don't want to do. Sometimes the hardest part of taking care of patients with difficult problems and lots of need is managing my own thoughts and emotions. Once I have myself under control, helping the patient is often straightforward.
This interview has been edited and condensed.