While legislators and physicians continue to develop new policies for opioid prescriptions, the epidemic remains alive.
Richard Bundschu, MD, is a pain management physician at Coastal Orthopedics in Bradenton, Fla. He highlighted the evolution of pain management physicians and role providers have in the opioid epidemic.
Question: What are the trends among physicians in regard to legislation about opioid restriction?
Dr. Richard Bundschu: With the current atmosphere surrounding opioids, primary care physicians are somewhat apprehensive about prescribing opioids to patients directly. They instead are referring them to see a pain management physician, which can be a tad overkill. Pain management physicians are often associated with being opioid prescribes. However, the job requires so much more. It's an unnecessary side effect of the latest regulations for primary care physicians to feel the burden of the reputation of opioid prescription patterns and pass a patient off to a specialist when it may not be required.
Q: What are physicians' roles in the fight against the opioid epidemic?
RB: We are the primary gatekeepers. Part of our task is to be an empathetic Mother Teresa but the other challenge is to be Sherlock Holmes to determine if the patient needs narcotics. If the patient is not a candidate for opioids, it doesn't matter if the patient gets upset. If the answer is no the physician needs to hold strong, no matter how uncomfortable the situation may become. A lot of times, because of social media, if you decline a patient's opioid request, they get upset and write poor reviews online. It's a challenge from a variety of angles.
Q: Are there differences in prescribing patterns between new and experienced surgeons? What steps need to be taken to change the stigma of pain free to managing pain?
RB: Back in the mid-90s, we as a specialty felt we were under prescribing. We didn't feel as if we were taking patients' pain seriously and there were less regulatory efforts. So, it wasn't uncommon to go to a national pain conference or spine conference and see lecturers promoting opioid awareness due to under prescribing. However, now it is almost a complete 180-degree flip.
In the big picture, opioids are one tool in our tool box. If someone has acute pain, you often know the direct source or location. However, the issue with chronic pain is the signal goes from the source, up the spinal cord and then to the brain and the brain doesn't know how to respond. From an evolutionary standpoint, pain is a good thing, but chronic pain doesn't have the same responses. Historically, the only classic pain medicines we knew were opioids, which worked on the mu receptor, and non-steroidals. Over time, physicians began to learn about other receptors, and it was realized there were a lot of receptors that worked with pain that went previously unnoticed.
When you talk to some of the younger physicians, their training is different. Now it is focused on getting the pain under control through surgeries or interventional procedures. We as treating physicians are the gatekeepers. Yes, we have lots of tools, and the question is determining which treatment each patient needs. The majority of patients don't need surgical options immediately, so we developed an algorithm to exhaust conservative treatments first, then minimally invasive options, and if these fail, then it's time to reevaluate surgical options.
Q: Has the rise of value-based care helped conservative treatment options?
RB: This is a [interesting] question because if you are a spine surgeon, the answer to treatment is often going to lean toward operating. Insurance companies are always looking for ammunition to not pay for different services, whether it is physical therapy, MRIs or surgery.
For the surgeons who embrace these protocols, it's a good thing. However, there are a lot of surgeons who view less invasive, conservative treatments as bureaucratic stumbling blocks. You can view them both ways. I think the key is to put the patient through an algorithm, so they get what they need because not everyone needs surgery. It is imperative to know what is causing the pain and this is not always easy.
Q: What is the No. 1 thing physicians need to know about pain management, opioids and future trends?
RB: Keep your eyes and ears open because the regulatory agencies are changing the rules very quickly. As responsible prescribes, we need to ensure that the patients get what they need. Physicians need to use databases and other resources to verify patients are not doctor shopping.
With the technological advances and rigorous scientific inquiry, we will continue to evolve with our treatment options. However, it is often difficult to predict the future.