Chronic pain physicians experience significantly worse physician burnout than other physicians,1 and physician burnout may be a contributing factor to the opioid epidemic2. Physicians suffering from physician burnout may not possess enough time or energy to fully explore non-opioid alternatives to chronic pain patients. It is a vicious cycle, but there are strategies physicians can use to break it.
Patients in chronic pain with behavioral health disorders and substance use disorders present a potentially high risk for misuse of prescribed opioids.3 Managing the chronic pain of a drug-seeking, doctor-shopping patient requires a level of vigilance, expertise, and discipline that may seem impossible in a busy practice. Determining why a patient is seeking opioids can help simplify the process of managing the individual’s healthcare in a way that will not increase the risk of burnout. Although there is overlap, there are three main categories of patients who pressure physicians for opioids: opioid dependent chronic pain patients4, patients with opioid use disorder5, and patients who are diverting their medications.
Following are tools and resources to help identify and manage these drug-seeking patients. There are also increasing numbers of resources for individuals with opioid addiction and for chronic pain patients who have developed opioid dependency that interferes with their medical care. Being prepared with policies and protocols can help alleviate the stress of managing these challenging patients.
Full participation by all prescribers in prescription drug monitoring programs (PDMPs) is emerging as an effective strategy for mitigated the risks of patient drug diversion. The following patient behaviors may also indicate that your patient has an opioid use disorder or is planning to sell or give opioids to others:
Some patients requesting pain medications may not be in pain. It can be very difficult to determine which patients require pain relief and which patients plan to misuse the medications. Different roles within a practice often necessitate different strategies. The following resources describe strategies for different roles:
Thinking of opioid use disorder as a long-term chronic medical condition like diabetes or cardiovascular disease can reorient the physician to a role as healer. Treatment of opioid use disorder may require referral to other medical, behavioral health, or community and recovery support services. Having a plan in place for assessing, treating, and referring patients with opioid use disorder can help reduce the stress associated with treating these patients.
Without a carefully crafted pain management plan, opioid therapy can be deadly for a patient with an opioid use disorder. Continued prescribing of opioids for a patient should be contingent on assessment and reassessment of the efficacy, risks and benefits of doing so. It is also important to understand and comply with state and federal laws and regulations that control opioid prescribing practices. Policies, protocols, clinical tools, and a clear understanding of the laws and regulations can make decision-making and management of a drug-seeking chronic pain patient easier.
More Information on Managing Challenging Patients
|
1. Steve A Hyman, et al. “Prevalence of Burnout and Its Relationship to Health Status and Social Support in More than 1000 Subspecialty Anesthesiologists.” Regional Anesthesia & Pain Medicine. 2021;46:381-387. DOI: 10.1136/rapm-2021-102530
2. Steven A. Adelman. “The Opioid Crisis and Physician Burnout: A Tale of Two Epidemics.” Harvard Health Blog. June 8, 2016.
3. Yu-Ping Chang, et al. “Management of Chronic Pain with Chronic Opioid Therapy in Patients with Substance Use Disorders.” Addiction Science & Clinical Practice, 2013, 8(1), 21.
4. J. Kimber Rotchford. “Opioids: Addiction or Physical Dependence?” Practical Pain Management, Updated on: May 13, 2019.
5. American Psychiatric Association. “Opioid Use Disorder.” Reviewed December 2022.