UCLA is a leader in medications for addiction treatment (MAT) for people with opioid use disorder. We spoke with Dr. Kenneth Pettersen, a primary care physician at Olive View-UCLA Medical Center, to learn how the center treats patients with opioid use disorder and chronic pain.
How do you typically identify patients who have both OUD and chronic pain?
We screen all of our patients on chronic opioids for features of OUD and other substance use disorders and do routine review of CURES and urine drug screens.
When patient are diagnosed with chronic pain and OUD, are they referred into the medications for addition program (MAT) program for the OUD or are they part of a different program?
We generally try to keep patients with chronic pain and OUD assigned to their primary care physician [PCP] and offer a home start with buprenorphine. If they have trouble transitioning, they are referred to our MAT clinic for closer follow-up and titration.
Do you have standard protocols developed for patients once both diagnoses have been identified? If so, can you describe them?
For patients with chronic pain and comorbid OUD, we have a low threshold to transition to buprenorphine-naloxone. We generally encourage PCPs to continue to follow these patients but may have more experienced providers help with buprenorphine home starts. We allow some patients to trial an opioid taper, though most patients elect to transition to buprenorphine.
Are there any differences in buprenorphine prescribing for patients with chronic pain and OUD?
We generally encourage minimally tolerated split-dosing of buprenorphine for patients with chronic pain with aggressive use of non-opioid adjunctive therapies. For patients with OUD without chronic pain, we generally prefer higher, once-daily dosing. We typically see patients with chronic pain less frequently, though at the end of the day, the treatment approach depends on achievement of treatment goals.
What members of your care team are involved in treating patients with chronic pain and OUD?
Most of our X-waivered providers [physicians qualified to treat OUD with buprenorphine in clinic offices] have at least some experience in treating both OUD and chronic pain. For more complex cases, we have MAT/chronic pain champions who are able to help patients transition from opioids to buprenorphine. In some cases, patients can change PCPs if their patient’s assigned PCP is uncomfortable managing treatment.
What are the most significant challenges you’ve faced in treating patients with chronic pain, and how have you addressed those challenges?
The most significant challenge is building an alliance with patients such that they trust you to not abandon them and their quest for pain control. At the same time, we try to “do no harm” and avoid therapies that provide more than just short-term relief.
Now that your clinic is more robustly managing pain, what impact has this had on your MAT program?
For OUD patients in our MAT clinic, we are realizing that more patients who come to us using heroin initially started with taking prescription opioids. This helps us to remember to make sure we’re addressing not only the addiction but to identify and treat their longstanding chronic pain, which can be an important trigger for disease relapse.
When providing interventions for patients with chronic pain and OUD, how do you tell patients that the misuse of opioids also needs treatment? Patients denying a problem and fear of “being treated like an addict” is a common response with patients with chronic pain and OUD. How do you provide education and support?
We try to normalize the physical dependency that commonly occurs when people are exposed to chronic opioids and highlight the historical influence of Big Pharma and culture. We also focus on the safety profile of buprenorphine and the likelihood of better pain control as up-titration of dosing is safer. Furthermore, we emphasize the regulatory and formulary benefits of buprenorphine, such as refills, that is true at least for our patient population.
As you’ve improved the management of patients who have co-morbid OUD and chronic pain, what has been most rewarding?
The most rewarding aspect is transitioning the patient-provider relationship from one of hostility to one of partnership. Many patients who previously had high rates of acute care utilization are now achieving better pain control and improved function.
As clinics begin to focus on improving how they manage patients with chronic pain, what key steps do you recommend they take?
The most important strategy is to set clear expectations among patients and create space in clinic schedules for frequent follow-up. It is equally important for clinics and health plans to provide a broad menu of pharmacologic and non-pharmacologic therapies, such as topical ointments, cognitive behavioral therapy, and joint injections.
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