Part XI: Epilogue
BY JIM HUIZENGA, M.D. AND CHIEF CLINICAL OFFICER OF APPRISS HEALTH
Series Introduction – Appriss Health has long held that chronic pain and addiction (substance use disorder) are separate medical conditions and that each deserve a unique clinical approach. We have spent years developing clinical decision support tools and in doing so have obtained the feedback from countless medical professionals, including many pain providers. Through those providers we have also heard (directly and indirectly) from many chronic pain patients as well.
To continue this conversation, over a long series of blog posts, we will explore our approach to benefit/risk assessment, data presentation, and clinical support…and how they relate to our goal of creating a usable and balanced, clinical viewpoint that protects access to care while highlighting areas of risk that clinicians and patients should be aware of.
Back to the Beginning.
Way back at the beginning of this series I penned a few questions at the end of the first post. The questions involved a hypothetical patient who was started on opioids for chronic pain and for whom they appeared to result in a net benefit. The questions were:
- What is the benefit/risk assessment for Chris?
- Does the benefit/risk assessment justify or validate the use of opioids for Chris’ chronic pain?
- Can anyone besides Chris answer this question?
Let me turn this epilogue into a bit of a prologue and let’s talk about “Chris.” Chris (name changed) was my first patient who died of an unintentional overdose. She was a frequent patient in my emergency department (ED) and was frequently seen in other EDs around the area as well. Chris had what we would now call a dual diagnosis…chronic pain and substance use disorder.
Chris came to the ED for pain medications and it was usually very hard to discern whether it was the pain or the substance use disorder that was driving her visit. My partners and I all had different approaches back then. Some gave out prescriptions to patients like Chris and some, instead, recommended specialized treatment by an addiction specialist. I was in the latter category, but that didn’t mean I didn’t care about her pain. I did care about all the forces driving her use and misuse of prescription pain medications.
One day I came to work and saw that Chris was already in the ED being seen by one of my partners. I had just seen her a couple of days ago and told her we should really get her some help (which she refused). Before I saw any of my other patients, I went to see how she was doing. What I discovered was that she was on a ventilator. She had suffered an overdose and had irreversible brain damage. She would die in the hospital a few days later.
So, let’s go back, and with hindsight, answer those questions for Chris.
What is the benefit/risk assessment for Chris?
Chris’ problem started with pain, and in the scenario in the fist blog post, she received pain medications and had a pretty good improvement in her PEG scale. Missing from that post was the fact that Chris smoked as a teenager, drank alcohol (at times excessively), and had multiple family members who had substance use disorder…so the benefit/risk assessment is at best cloudy. It appears she has high benefit and high risk.
Does the benefit/risk assessment justify or validate the use of opioids for Chris’ chronic pain?
This is a very tough question to answer, isn’t it? Now that we know what eventually happened to Chris it might be easy to say that the risks outweigh the benefits. Blinding ourselves to the outcome, perhaps the best strategy would have been a very tightly controlled trial of pain medications with frequent monitoring (urine drug screens and PDMP checks). If Chris was able to manage her medications well and achieve a better quality of life, then continued use could have been justified.
HOWEVER, a benefit/risk assessment is not a one-and-done assessment. It must be an ongoing part of Chris’ care going forward. It seems that given the outcome, at some point in time, it should have been obvious that the risks outweighed the benefits and a new treatment plan should have been put in place. Obviously, the earlier the better.
Can anyone besides Chris answer this question?
Since medications like opioids are controlled substances and require a prescription, at least three people (Chris, her doctor, and her pharmacist) must all agree on the therapy in order for it to progress. In the setting of a difficult benefit/risk decision, I personally lean towards making sure the patient understands the risks fully, but ultimately letting him or her make the decision. So, at the outset, given a mixed benefit/risk assessment, it probably should be Chris who makes the decision. Again, we know what happened to Chris, and in the end, she was unable to make appropriate decisions for herself. At some point in time, someone besides Chris needed to make a different decision for her.
That IS the job of the doctor (provider) and the pharmacist. It is a tough job, and a constant balancing act. It requires art, compassion, empathy, and the will to constantly do what is right for the patient…in the beginning, the middle, and the end.
Perhaps those were unexpected answers given the nature of the previous posts, but the precept contained in the first blog post…“Opioids are risky” is plainly evidenced with what happened to Chris. The key element to remember is that for many patients (especially chronic pain patients) there are benefits to using opioids that must be taken into account and the ratio of benefit and risk is what’s important. Even “high risk” can (and should be) offset by “high benefit.”
Offsetting Chris’ outcome above, I have seen many chronic pain patients in the ED who have a better quality of life because of their medications, and who use them appropriately and carefully. Because of the pain medications these patients take, they are able to work, get adequate rest, go for walks, and generally lead a more normal lifestyle than if they didn’t take the medications.
So, what’s the key message contained in this series?
Patients and providers should work closely and openly together to decide IF beginning chronic opioid therapy is appropriate. Factors to consider include the expected benefits and individually assessed risks that take into account past substance use, family history, etc.
IF chronic opioid therapy is started, it should be done so as a trial and with defined goals. It makes sense to agree ahead of time on events or outcomes that will result in early discontinuation of the trial.
IF chronic opioid therapy is deemed to have a net benefit and therefore continued, it must be closely monitored for both continued benefit and stable risk.
Implicit in the above is the simple fact that if a patient has been on a higher dose of medication for a longer period of time, like many chronic pain patients have been, and they are in general leading a more normal life because of them, then alterations (i.e. reductions in dose) should be carefully considered. The question to answer in the situation of an established patient with chronic pain on chronic opioid therapy is whether or not the current benefit and risk ratio is appropriate. As we’ve seen, that’s a complex question to answer, but nonetheless, that IS the question.
The above key message is the guiding light for Appriss Health’s work in the PDMP space. We respect the autonomy of the patient and the provider in determining a course of treatment and our goal in creating and providing the enhanced PDMP reports, scores, and management tools are to make it easier to evaluate and manage opioid use (and risk) and to make such actions a routine part of care. We must as a society, and we do as a healthcare information technology company, provide the tools that make that delicate balancing act possible.
To read more on this series:
- Part I – Benefit and Risk
- Part II – Risk Defined
- Part III – Dependence and Addiction
- Part IV – PDMPs
- Part V – Multiple Provider Episodes
- Part VI – PDMP Visualization
- Part VII – Interpreting PDMP Visualizations
- Part VIII – Scoring PDMP Data
- Part IX – Understanding How PDMP Data is Scored
- Part X – Machine Learning