Primary care providers like me find themselves at the center of a major public health crisis, one that was, in part, brought about by our own prescribing practices.
Twenty years ago, medical providers were being called out for under-recognizing and under-treating pain. We were told that effective treatments were available, but weren’t being prescribed.
In response, many practices, including my own, began assessing pain as the “fifth vital sign,” meaning that as patients were having their weight and blood pressure checked, they were also asked whether they had any pain, and if so, to rate it on a scale from 1-10. Not surprisingly, many cases of pain were identified.
What happened next is the result of the complex interplay between a largely well-meaning profession that is trained to heal and alleviate suffering, a popular culture that expects simple, effective treatments, and a pharmaceutical marketing juggernaut using misrepresentation and money to lure patients and providers into using their products. Opioid analgesics were once rarely prescribed for conditions other than terminal illness or post-operative pain. However, between 1997 and 2007, there was a 600 percent increase in their prescription for a wide range of painful conditions.
We have learned since that these medications are doing more harm than good. We now know that they can be highly addictive and are often misused, abused, or diverted to others.
We also know that there is little or no evidence that they reduce pain or increase functioning in most cases. The evidence does demonstrate that prescription opioids are associated with a significant risk of serious harm including addiction, overdose, and death. In addition, these medications often provide a deceptively easy path to abuse of other drugs, particularly heroin.
Studies have suggested that over 30 percent of chronic opioid analgesic users may develop prescription opioid abuse disorder. Prescription drug abuse is now the fastest growing drug problem in the US.
To solve this problem we have to focus on primary care. There are not enough pain specialists in the country to manage even a fraction of the over 100 million patients with chronic pain, most of whom seek care from a primary care provider. Over the past several years, my practice has tested a new approach using technology to help primary care providers learn how to treat pain and opioid addiction more effectively.
This project has three main components: The first is called Project Extension for Community Health Outcomes (Project ECHO).
Project ECHO is a recurring videoconference that links primary care providers with expert specialists in the field of pain management and opioid addiction. Primary care providers attend these sessions regularly and learn new approaches to care by presenting real patient cases of their own and by listening the cases presented by their colleagues.
The second approach, eConsults, uses simple messaging technology to allow primary care providers to securely transmit information to a specialist about specific cases and to receive recommendations back within two days.
Third, we have designed group learning activities called Practice Improvement Collaboratives that engages medical providers and their support staff to learn how to adopt best practices for pain and opioid addiction treatment into their practice.
We have successfully used this approach at Community Health Center, Inc. (CHC) and it has been adopted far beyond Connecticut. Today, there are more than 140 primary care providers from 19 states who join into our live Project ECHO sessions, use eConsults, and/or participate in our practice improvement collaboratives.
The results have been very promising. At CHC we’ve now treated over 850 patients for opioid addiction with buprenorphine in our primary care practices. We’ve also seen a significant drop in the overall prescribing of opioids with an increased use of behavioral health interventions and other complementary strategies such as chiropractic care and physical therapy. In addition, our providers are acquiring new knowledge and gaining confidence in managing pain effectively.
There are real and effective solutions to address the opioid epidemic, many of which are being employed right now. The solutions aren’t more pills or new high tech medical therapies. The solutions are connecting people and collaborating across disciplines to unlearn the old ways, and embrace the new ones.