Amy C. LaHood, MD, MPH, has been a family practice physician for 17 years and has been affiliated with the St. Vincent Hospital (Indianapolis) residency program for the past 12 years. In 2012, she became involved with the Indiana Attorney General’s Task Force Prescription Drug Abuse Prevention and was involved in statewide efforts to curb over-prescription of opioids for both acute and chronic pain management. While she continues her outpatient primary care work as part of St. Vincent Medical Group, she also has consults, traveling the state of Indiana to educate physicians, communities and law enforcement about the dangers of opioid over-prescription and medical alternatives for chronic pain management. She is also working with St. Vincent to set up a clinic for pregnant women with opioid addiction. 

Physicians want to help their patients manage chronic pain. For years, opioids were the standard of care. Opioid abuse has led to epidemic addiction rates, as noted in the recently published Behavioral Health Barometer from the Substance Abuse and Mental Health Services Administration.

Dr. Amy LaHood describes her efforts in Indiana to educate primary care providers in alternative medicines and therapies for chronic pain management.

“We have good data that tells us that in every state across the country, it’s more likely for a patient or a person to die from a prescription drug overdose than a car accident,” said Dr. LaHood. “That’s how big the problem is.”

In response to this epidemic, in Indiana, as in 49 states across the country, legislatures have adopted stricter standards for opioid prescriptions. Dr. LaHood worked with state legislators on this issue and explains, “Now by Indiana state law, any patient that’s on a minimum of three months of opioids consecutively has to have a treatment agreement in place. And there are very specific things that must be within that treatment agreement. Further, most states now have prescription drug monitoring programs requiring providers to check the registry before treating a patient’s chronic pain and monitoring their prescription use of those drugs.

“In Indiana, we cut the number of opioid prescriptions by 11 percent; but now we are definitely seeing an increase in heroin use and overdose.”

Dr. LaHood believes other primary care providers listen and engage her in discussions of alternatives for opioids in chronic pain management because she understands their dilemma of wanting to help a patient in chronic pain and the difficulty of getting patients to “buy in” to opioid alternative therapies.

“In the United States, we have an aging population, many with the burden of chronic illness,” said Dr. LaHood. “We know that anywhere from one in 10 to one in four patients that walk through the door of a primary care office has some kind of pain. These patients are often very difficult to treat because often they may have been treated with opioids and have developed a tolerance.

Dr. LaHood points out that in certain instances opioids are very appropriate for acute pain and palliative care, and they can play a part in the comprehensive approach to pain management. “We need to find ways that are safer and more sustainable for our population that don’t carry the risk of abuse, addiction and tolerance.

“But we now also know, in some post-operative cases, we need to go toward something called multimodal therapy, where we don’t use opioids in isolation. We can maximize other medications that also are very effective to treat pain, such as NSAIDs, such as Tylenol, and other comfort measures that we know help with pain.

“Probably the most challenging issue of all is: How do we take care of the tolerance generation of patients? This is the group of patients that were put on these medications by well-intended physicians, and at this point it’s not easy to just take them off because their brain and their body has gotten used to this medication.

“We are always teaching primary care residents to optimize non-opioid therapy,” Dr. LaHood continued. “And when it comes to a point where opioids are the best treatment option, we must check patients’ previous drug usage and get a patient treatment agreement on board.” 

“We have to make sure that we have more focus on functional goals in chronic pain management and alternatives like physical therapy so that if the patient doesn’t achieve those goals, we can back down on the kinds of drug treatment that has potentially adverse effects.”