Pain, Opioid Addiction Addressed Simultaneously in Special Clinic

“We need to train our way out of the opioid crisis,” said Kaylin Klie, M.D., M.A., at the American Society of Addiction Medicine’s annual conference in April in Baltimore.

The use of opioid medications—most often prescribed in primary care—has risen sharply in recent years, despite a lack of evidence for their efficacy for noncancer pain, noted Klie, an instructor in psychiatry at the University of Colorado School of Medicine in Aurora. In 2014, 19,000 Americans died from overdoses of prescription opioids.

Denizens of separate medical silos traditionally have had a hard time crossing professional boundaries, said Klie.

“Addiction providers are uncomfortable treating pain; pain management providers are uncomfortable treating addiction; and primary care people are uncomfortable treating either,” she said.

The University of Colorado has tackled that problem by establishing a Controlled Substance Clinic (CSC) within its Family Medicine primary care clinic.

The CSC was set up under the direction of Patricia Pade, M.D., an assistant professor of family medicine and the program director of the University of Colorado Addiction Medicine Fellowship. Pade was formerly director of the Co-occurring Disorders Clinic at the New Mexico Veterans Administration Health Care System, and the Colorado clinic is modeled on that experience. Fellows from the Addiction Medicine Fellowship take part as well, both treating patients and working to educate their primary care colleagues.

The clinic evaluates, treats, manages, and monitors comorbid pain and addiction, focusing on high-risk opioid patients, said Klie. “High-risk” includes younger patients and individuals with a family or personal history of substance use disorder or with a comorbid psychiatric disorder.

“We treat both chronic pain and addiction at the same time,” she said. “We tell them that chronic opioid therapy has never been shown to be successful over a lifetime. We take an hour for the initial intake visit, but we’ve found that it’s rare to assess opioid dependence or substance use disorder in one visit. Building trust between patient and provider over time helps as they taper off opioids.”

Patients worry that if they enter addiction treatment, their pain will not be addressed. So work often begins by dealing with pain to lessen the patient’s fear of losing medication. Treatment may include using drugs and behavioral therapy for pain to reduce opioid use.

Patients can move in either direction between primary and addictions care. The CSC providers are available for immediate consultation from their primary care colleagues, who develop a better sense of pain and addiction as true medical conditions, lessening stigma. It also means that every patient has a primary care physician, allowing treatment of the whole patient.

“Patients with co-occurring chronic pain and opioid dependence can be successfully treated in a primary care setting,” said Klie. “Buprenorphine or naloxone can be successfully used with adjunctive treatments available to primary care providers.”

Following treatment, pain scores drop on average for these patients. Furthermore, about 77 percent remain in treatment, about half in primary care and the rest in the CSC.

Most of the behavioral health care is provided by two psychologists on the team. Psychiatrist Laura Martin, M.D., an associate professor of psychiatry at the University of Colorado School of Medicine, is co-director of the fellowship and connects any patients with serious mental illnesses, such as personality disorders or schizophrenia, to a psychiatrist.

Klie sees her clinic as a step toward future modes of expanding treatment.

“The meat and potatoes of medicine come in training,” she said. “We can train ourselves, our patients, and the upcoming generation of physicians while we show that patients can be cared for without antagonizing their doctors.” ■