Chronic Pain Management and Opioid Misuse: Guidance for Family Physicians.

This issue of American Family Physician features a summary of the American Academy of Family Physicians’ (AAFP’s) updated position paper on opioid abuse and pain management.1 Chronic pain and opioid misuse have intersected as significant public health crises, and family physicians deserve the most accurate guidance to address these issues. Despite growing concerns about overprescribing of opioids in primary care, there is a paucity of evidence on effective and safe treatments for chronic noncancer pain. Several factors have contributed to increased prescribing of opioids without concomitant increases in reports of pain or prescribing of nonopioid analgesics. Physicians have been challenged to treat pain aggressively and to focus on pain management as an important measure of patient satisfaction, and new opioids have been developed.2,3 The increasing morbidity and mortality associated with opioids suggest that better approaches to chronic pain management are needed. Unfortunately, guidance based on high-quality evidence is lacking. Although the news media, other medical organizations, and state and local governments have promoted the new guideline on opioids from the Centers for Disease Control and Prevention,4 its recommendations are not consistently based on strong evidence. The AAFP declined to fully endorse this guideline but gave it an affirmation of value, meaning that the guideline is useful but has significant limitations.5 To promote the best evidencebased strategies, the AAFP provides members with a toolkit to help develop policies and protocols for pain management (http://www.aafp.org/patient-care/publichealth/pain-opioids/cpm-toolkit.mem.html). Despite limited evidence and unanswered questions, the AAFP’s position paper on chronic pain management and opioid misuse includes calls to action at the individual, practice, community, education, and advocacy levels.5 Family physicians must have a role in identifying opioid use disorders and referring patients for treatment, if not directly providing treatment through medication-assisted therapy. The position paper focuses on buprenorphine therapy; however, few physicians have a valid Drug Addiction Treatment Act of 2000 waiver to prescribe buprenorphine, and only a small percentage of those who do actually use it. Medication-assisted therapy is not the only solution to opioid misuse, but it is part of a multifaceted approach that must also include prevention, harm-reduction strategies, new and innovative treatment approaches, and reintegration services for patients. Family physicians are committed to advancing population and community health, and we must take the lead in reducing opioid misuse and overdose before outside entities mandate practice strategies that may not be patientcentered. Substance abuse disorders remain a stigma, and physician offices must be safe places for nonjudgmental diagnosis and treatment. Although we certainly cannot tackle this challenge alone, we have a clear opportunity to combat the problem of opioid misuse.