Has the Pendulum Swung Too Far on Restricting Pain Management?

Patients taking prescription opioid pills for their chronic pain might find it hard to find primary care, according to a new study.

The study, published in JAMA Network Open by researchers from the University of Michigan, showed that in a random sample of Michigan primary care clinics, 40% of clinics of 194 primary care clinics contacted for the study were not willing to accept a new patient who was on opioid therapy, no matter what kind of health insurance they had. 

“We often hear about patients with chronic pain becoming ‘refugees’ when they are abruptly tapered from their opioids or their current physician stops refilling their prescription,” says lead researcher Pooja Lagisetty, MD, MSc. “There have been no studies to quantify the access these patients have to finding a new primary care doctor when this situation occurs. 

“This finding is concerning not only because it demonstrates how difficult it may be for a patient with chronic pain to find a new primary care physician, but it also raises questions about what happens next,” Lagisetty says. “Where will these patients find relief for their pain? Will they turn to more dangerous illicit opioids? Who will manage their other medical problems such as their diabetes and hypertension?”

CDC to blame?

Some blame the CDC guidelines for the pendulum swinging too far on restricting pain management, according to Lagisetty.

“I suspect this is only a small part of the problem as states and healthcare systems have implemented various policies to curb prescribing that are only occasionally based on the guidelines,” she says. “How much of this is related to being overburdened from recent changes to policies? How much of this is stigma against patients on opioid therapy? How much of this is due to fear of legal repercussions?”

Lagisetty believes that healthcare executives should understand that not every patient is the same and should be careful about one size fits all policies at their health systems. 

Related: The Impact Of Preoperative Opioid Use On Patient Outcomes

“There has to be some flexibility for physicians to make these decisions and an overall encouragement to provide equitable care to all patients, not just those who fit certain health profiles,” she says. “I also feel there is a way for each system to understand how to better equip primary care practices with the resources they need to juggle what can be very time-consuming administrative requirements to prescribing opioids.”   

Surprisingly, the researchers found that willingness to accept a new patient did not differ by insurance status, which contradicts previous studies that have shown that patients on Medicaid tend to have lower access to primary care than those with private insurance.

“This may indicate that the decision to restrict access is not based upon reimbursement,” Lagisetty says. “Additionally, larger clinics and community health centers were more likely to accept new patients suggesting that there may be some system level factors that may improve access to care.”

The top three takeaways from the study are:

• Chronic pain patients on opioid therapy have limited access to primary care providers, which could lead to negative health outcomes, such as lack of care for their other medical conditions or more dangerous transition to illicit opioid use to help manage their pain.

• Insurance status did not affect the likelihood that patients would be accepted, indicating that clinic acceptance may not be unrelated to reimbursement policies.  However, large clinics and community health centers were more willing to provide care suggesting that there may be health system level factors that may improve access to care, according to Lagisetty.  

• Additional research is needed to understand reasons why primary care clinics are reluctant to accept chronic pain patients on opioids to inform policy change in the future.