Treating Patients Using Opioids with Dignity

I'm a member of the ACOFP/ACOI Opioid Education Task Force, which supports the production of the "De-stress Pain Management" curriculum on opioid education, currently being expanded for 2025. As I reviewed the past educational materials, I came across a presentation that moved me deeply and compelled me to share my thoughts with a wider audience. In this presentation by Dr. Kathleen Farrell and Dr. Robert Agnello, which was part of the live case forum at ACOFP '24, they asked the audience to give them cases regarding complex chronic pain patients. As I watched this session, I started to get tears in my eyes. The instructors mentioned were not just highly knowledgeable, they were also compassionate.

I have been a hospice/palliative care physician for over 20 years and have seen several changes over those years as to how chronic pain patients are treated. Right from the start, like all of you, I always tried to use opioid alternative treatments when effective and, when opioids were needed, to use the lowest dose possible for the least amount of time. However, amongst my colleagues, I began to see a shift in how chronic pain patients were treated. (I am probably guilty of this with some patients, too.)

For the most part, we treated these patients like criminals or even lepers. We could never trust them! They were bad to be on opioids, and we were bad to put them on opioids. A couple of the stories offered during the presentation were about "legacy patients," meaning that the physician presenting was not the one who put the patient on opioids; somebody else did this dastardly deed. We were also bad if we kept patients on opioids. Physicians and patients could be bad in so many ways!

I was once on a hospital task force for chronic pain. After a few months, it was clear that the goal was to have these patients leave our health system if they did not comply with our regimens. Each patient was seen by physical therapy and behavioral health, which were good things, but not when the goal was to stop the opioids, regardless of how well the patient was doing or the pain was controlled. And oh, the glee that occurred if a patient made a mistake about their opioid usage. You would have thought that the clinicians had just solved the crime of the century! A patient in this category would receive a dismissal from the practice letter very quickly.

The next trend was to diagnose almost everyone on opioids as having opioid use disorder (OUD). As Dr. Farrell noted, that is pretty easy to do, especially if patients are insecure about getting their chronic opioid medications refilled. Many probably do go through withdrawal, especially if their physician is not available, or their pharmacy is out, or a mistake was made, or the office did not respond, or the patient made a mistake. Several physicians specialized in comprehensive medicine, which took these patients on. Some of these physicians were very good at working with primary care physicians. Some were very bad and wanted to completely take over the patient's care, or else. I knew of some patients who were told on their first visits that it was criminal that they were on opioids, and they had to come off of them as soon as possible.

Palliative care has also seen some changes in the last few years, including even the fundamental question of what defines a palliative care patient. Dr. Diane Meier from the Center to Advance Palliative Care used to emphasize that patients were eligible for palliative care if they had chronic life-limiting diseases without regard to prognosis. These patients have diseases that cannot be cured and will most likely take the life of the patient, but we do not know when. This could include chronic heart disease patients, dialysis patients, patients with multiple sclerosis, patients with liver disease (Bud-Chiari Syndrome), and many others. Many studies show that these patients often have chronic untreated or poorly treated pain. There is a trend for some palliative care clinicians to not see these patients because, quite frankly, they are not dying quickly or predictably enough.

Maybe that's not a bad thing; palliative care should not take care of all the chronically ill patients who are in pain. Primary care physicians and other specialists should also be involved.

Education like the presentation from Dr. Farrell and Dr. Agnello helps alleviate some of these problems and stigmas, resulting in better care for individuals with chronic pain. Physicians should not be embarrassed to have patients on opioids on their list and should be free to talk about them with their peers in hopes of finding solutions. Drs. Farrell and Agnello emphasized this. The goal is to help, not punish. Urine drug testing (and other safety programs) should be done to identify problems, not as an excuse to discharge patients.

I am more than impressed by the members of this group and their goals for this program. I am honored to be a part of this!

To explore our current "De-stress Pain Management" curriculum, visit the ACOI Online Learning Center. This course is worth 8 CME credits and compliant with DEA education requirements. There is also a self-assessment exam that complements the curriculum for those already well versed in pain management.

Note: The views expressed in this article are the author’s own and do not necessarily represent the views of ACOI.