Treating Pain During an Opioid Epidemic in the Primary Care Setting

April 25, 2019

Perspectives in Primary Care (formally the Primary Care Review) features perspectives from practitioners and students representing organizations, practices, and institutions across the country and around the world. All opinions expressed in this article are owned by the author(s).

By: Mahmud Ibrahim, MD and Linda Girgis, MD

According to the CDC, there are an estimated 50 million adults (or 20.4% of the population) in the US suffering from chronic pain. Additionally, there are 19.6 million adults with high-impact chronic pain. Chronic pain is defined as pain that typically lasts for longer than 12 weeks. While pain may serve as a warning of possible injury, chronic pain can last for months to years.

Many chronic pain patients seek treatment in a primary care setting. These conditions can range from migraine headaches to lumbar radiculopathy as well as a whole host of pain conditions. While we’ve all seen the frightening statistics of the opioid crisis, the fact is that patients continue to get prescriptions for opioids. In fact, it has been estimated that 1 in 5 patients receive a prescription for an opioid for long-term use for noncancer related pain in primary care settings. In the US, more than 40% of overdose deaths involved the use of a prescription opioid. It is now estimated that more people die from drug overdoses than motor vehicle accidents or guns.

Primary Care physicians (PCPs) are in a unique position to make an impact on this epidemic. They are often the first physicians a patient seeks in their care and the ones who initiate the medications a patient takes. They also the ones most responsible for managing referrals to specialists.  As such, PCPs need to be more cautious in how opioid medications are prescribed. For example, in conditions such as tendonitis, first-line treatment should include NSAIDs, physical therapy, possibly chiropractic care, and acupuncture. Opioids have no role in the initial treatment of chronic pain. Other procedures such as injections, including corticosteroid injections or regenerative options, such as platelet rich plasma, as well as tenotomies should be considered. Many physicians under-utilize these methods of pain treatment that can potentially keep a patient off opioids. PCPs should learn more about these other options.

While pain can be a complex problem to manage, there are specialists available to help. There are Pain Management and Physical Medicine & Rehabilitation (PM&R) specialists. Primary Care doctors should refer to them whenever they are uncomfortable managing a patient’s pain or they want the patient to learn other options available to them. Orthopedists typically want to do surgery. However, there are many alternatives that these other specialists can do while avoiding surgery, or at least delaying its necessity.

Most states now have drug monitoring websites where physicians can look up prescriptions a patient has filled for controlled substances. Every primary care doctor (as well as specialist who prescribes opioids) should be utilizing these monitoring systems. Some states are now making it the law. While we do not yet have a nationwide system, many states are making theirs more interoperable.

No patient should even be prescribed an opioid without a review of their records. We’ve all seen cases where patients told us they were being prescribed a certain controlled substance and they were not. Also, a patient may be taking an opioid prescribed by another doctor and primary care doctors are responsible for coordinating the patient’s entire medical care. PCPs need to know what medications the patient is taking and why. And if they disagree with the treatment plan, such as the use of an opioid, then it is time to have a discussion with the specialist.

As patients live longer with more complex diseases, we can only expect the number of chronic pain patients to increase. Primary care doctors stand on the frontlines treating these patients as well as curbing the opioid epidemic. These goals often collide. In the meantime, PCPs need to follow appropriate guidelines in the management of pain and refer to available specialists when indicated.


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