Physician assistants on the front line in the opioid epidemic

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The role of physician assistants (PAs) within the healthcare landscape has grown increasingly important over the past several years. As PAs, we increase access to affordable, quality care for those who might otherwise go without, care for patients in every specialty and setting, and we often serve as frontline healthcare providers.

It only stands to reason that our role in battling the opioid addiction epidemic that grips our nation is also growing in importance.

In Fall 2018, the U. S. House of Representatives passed the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act of 2018.  A key component of the Act made permanent the ability of PAs, among other advance practice professionals, to obtain federal waivers to prescribe buprenorphine—a leading medication for treating opioid use disorder (OUD).

A recent article by Pain Medicine News stated that more than 30,000 PAs practice in primary care with another 2,500 in addiction and pain medicine. Our profession is expected to grow by 37% between 2016 and 2026. ¹ In other words, there will be more of us, and we will be treating more people.

It is critical that we, as PAs, recognize the signs and symptoms of opioid misuse, and understand the best practices and guidelines around opioid prescribing. We are and will continue to be called on to treat patients with legitimate pain and should therefore continue to develop our knowledge in this area to better serve this population.

Over the course of my career, I’ve worked in various settings, including private practice, hospital inpatient and intensive care units, in the operating room in neurosurgery, sports medicine, and in psychiatry.  I’ve found that although the specialties differ, there are commonalities across all regarding how we should view/prescribe opioids.

Open Communication. Appropriately managing a patient’s pain needs to be an early and ongoing part of your patient conversations – for those suffering from acute or chronic pain.  Any conversations about opioid use need to touch on the risks and benefits while setting realistic expectations. This includes how much pain relief should be expected, for how long opioids are generally appropriate, and more. Don’t be afraid to ask your patients questions. Understanding previous opioid use can help you plan treatment accordingly.  We all want to be judicious with our prescribing, and communication to ensure everyone is on the same page is key.

Treatment Planning. Every patient is an individual with differing levels of pain tolerance and ability to recover from injury or surgery. Treatment planning should consider best practices for the condition you are treating, the patient’s individual health situation, and ongoing conversation about what type of pain he or she may be experiencing. In neurosurgery, pain management was a daily part of our work. Whether a chronic back pain or post-surgery case, we developed protocols for how long patients should generally require pain medications.  We always worked under the assumption that pain should get better over time, not worse.  If a patient’s pain persisted past what was considered a normal timeline or seemed to worsen, we were taught to ask questions to try and determine the root cause of pain, rather than simply prescribe a higher dosage or longer-term use.  Often there are physical conditions that need to be addressed, which could be masked with additional pain medicine.

Expectation Setting.  There is no healthcare professional who would advocate for keeping a patient in pain.  But as we all know, after a surgical procedure, there will be some level of discomfort. Our charge is to appropriately manage that discomfort or pain, while setting realistic expectations for the patient. Part of expectation-setting means explaining that we want to be judicious or conservative in the use of narcotics. If pain can be reasonably managed with appropriate non-narcotic options, we should err on the conservative side. All too often, we’ve seen patients sent home with the perception of an open-ended opioid prescription “just in case.” We do them a disservice if we don’t set their expectations and manage pain conservatively.

Knowing the Signs. We never know who will become dependent on or begin to misuse opioids. Opioid use disorder can affect anyone, and many who develop this disorder are first exposed to opioids iatrogenically. In fact, of those in treatment centers for opioid use disorder, 50 percent of cases originated from prescription medication. ² As frontline healthcare providers, we need to recognize the signs of those who may be misusing opioids and compassionately intervene. There is a myriad of continuing education options to assist with this, whether the CDC’s guidelines or others. PAs should be able to identify signs and symptoms of opioid use disorder and initiate appropriate treatment when indicated. I would urge you to familiarize yourself with the available training and resources in your community.

Due Diligence. Like all prescribers, PAs are obligated to maintain accurate, up-to-date and detailed records of any narcotics we prescribe to patients.  In fact, many states require, or at least encourage, healthcare providers check the state prescription monitoring program prior to writing a new schedule to opioid prescription.  We all get busy with the tremendous effort that goes into patient care. But it is critical for our careers, practices and our patients to ensure that you remain in compliance with state and federal regulations pertaining to opioid prescriptions.  It is directly related to your credibility, license and ability to care for your patients.

There’s no easy answer to the opioid epidemic, but as healthcare professionals, we can certainly do our part in making sure that we are judicious in our prescribing, remain aware of potential misuse and understand the treatment options available.

 

¹ Pain Management News, January 28, 2019, The PA’s Role in Reversing the Nation’s Opioid Crisis by Melinda Moore Gottschalk, PA-C, MPAS, DFAAPA, Director-at-large, Board of Directors, American Academy of PAs.

² CDC 2018, Addictive Behaviors Nov. 2017

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