Can opioid treatment programs (OTPs) help pain patients who no longer need opioids for pain? Absolutely, says Elinore F. McCance-Katz, MD, PhD, assistant secretary for mental health and substance use at the Department of Health and Human Services (HHS). “For overuse and misuse of pain medications over time, which may have been initiated for a pain condition—I definitely think there’s a role for OTPs in this,” she told AT Forum.
One barrier is that the patients themselves don’t want to be considered “addicted,” and certainly don’t want to go to a treatment program that advertises itself as treating “addicts.” Another is that pain physicians themselves sometimes don’t want to be associated with addiction—and don’t even want to get the waiver to prescribe buprenorphine for their patients who develop opioid use disorders (OUDs).
Stigma of “Addict”
As assistant secretary at HHS, Dr. McCance-Katz is also responsible for managing and directing the Substance Abuse and Mental Health Services Administration (SAMHSA), and for leading SAMHSA policy and program development. So Dr. McCance-Katz understands the barriers facing patients, physicians, and OTPs. She cited an example. “I think there’s a certain stigma to using the word addiction with someone who believes they have a legitimate painful condition for which they received opioid therapy,” she said.
My own approach with those patients is not to use the word ‘addiction’ or ‘addict,’ but to discuss with them how these opioids have affected their life in a negative way,” she said. “It’s not just about dependence—it’s about overuse to the extent that it’s medically dangerous.” For example, overuse of opioids can result in periods of respiratory depression or aspiration pneumonia that could lead to death, she said. Another problem is that people on long-term opioids for pain “are not very active, and don’t exercise their lungs,” further exacerbating the respiratory issues, she said.
To help these patients accept treatment in an OTP for their OUD—because that’s what people who overuse and misuse opioid painkillers have—it’s best not to “label” them, but to “get them to tell you themselves about some of the negative ways opioids have affected their life,” said Dr. McCance-Katz.
As for helping people who are coming off high-dose long-term opioids get their lives back together, that’s exactly what OTPs do in providing comprehensive care, she said. “They have all the resources that are necessary to help that person.” And treating the OUD may not necessarily be with methadone—increasingly, OTPs are offering all three medications, said Dr. McCance-Katz: methadone, buprenorphine, and naltrexone.
“In my own clinical experience, so many people start out on opioids with pain, and legitimate pain,” said Dr. McCance-Katz. They were vulnerable to developing an OUD—and they did. “I talk to them about the positives and negatives, and they start to talk about the positives and negatives.”
It may be that the patient’s own pain management physician needs to taper a patient’s opioid medications before the patient can start taking methadone, because most OTPs are not allowed to induce patients at doses above 20 or 30 milligrams. “Pain management may need to taper them to a point where they can safely transfer over to methadone or to buprenorphine,” said Dr. McCance-Katz. “There are protocols for doing that (specifically, for buprenorphine, she noted, although she added that it is easier to go from buprenorphine to methadone than from methadone to buprenorphine).
Unlike methadone given for OUDs, methadone for pain is given in multiple daily doses. “I don’t think we have all of the science” to understand why we give methadone once a day for OUD but not for analgesia, she said. Both methadone and buprenorphine are long-acting drugs.
How does a clinician know if a patient on long-term opioids for pain has an opioid disorder? It’s based on DSM-5 and behavioral manifestations—not just tolerance and withdrawal, which are not necessarily pathological, noted Dr. McCance-Katz.
“One of the key questions, when you get people who are on these large doses of opioids, and who meet criteria for an OUD, is, what do you do with them?” she said. “What you don’t do is cut them off. Too often that’s happening. Will they go through withdrawal? You bet, and that is wrong—in my opinion, it’s inhumane. We have to have protocols in place, that is part of the individualized relationship between a clinician and their patient.”
The federal Centers for Disease Control and Prevention, in their guidelines for long-term opioid use, did not recommend cutting patients off immediately, noted Dr. McCance-Katz. Yet, many pain physicians are doing that. OTPs have the resources and the pharmacological know-how to induce methadone and buprenorphine.
But tapering? That’s hard for anyone to do, said Dr. McCance-Katz. “I don’t think this is an area that gets a lot of emphasis in training programs,” she said. “Often clinicians aren’t aware of what all the downstream effects are, of tapering, and especially of cutting patients off of their opioids,” she said. “We know how to taper opioids. We need to make these protocols available.”
In fact, the federal government is working to get clearance to release tapering protocols to the field, said Dr. McCance-Katz. “As a field, as prescribers, we cannot absolve ourselves of responsibility when we are the ones who started these medications, usually without good evidence of their effectiveness.”
Some emergency physicians have suggested that if patients come in in withdrawal from opioids, all they need to give them is some opioid—any opioid—to stop the symptoms. “The problem with that approach is that within a few hours they’re going to be right back where they started from,” said Dr. McCance-Katz of these patients, noting the problem will be particularly bad if patients are giving short-term opioids, like Dilaudid.
“In fairness to emergency medicine colleagues, they are under intense time constraints, and this is not the kind of work that should be assigned to them,” she told AT Forum. “Increasingly, EDs are looking to do this kind of work, but it’s really very difficult to give the person the proper assessment, to determine if they’re a candidate for any opioid,” she said. The patient also needs to be able to move on to a clinic quickly where they can continue treatment. “If you just give them a dose of opioids, you’ve done nothing except put off the problem for a few hours or a few days.”