Bridging Knowledge Gaps in Pain Management and Opioid Safety
In this video, Randall Hudspeth, PhD, MS, APRN-CNP, FAANP, discusses his presentation at the American Association of Nurse Practitioners 2025 National Conference on national trends in opioid prescribing and the critical role of primary care clinicians in managing patients with chronic pain or opioid use disorder. Drawing on his two decades of experience, Dr Hudspeth outlines the evolving national safety standards, the assessment and trial process for prescribing opioids, and strategies for long-term patient management. He also highlights recent advances in pharmacology and regulatory tools such as PDMPs, and offers practical guidance for providers navigating the complexities of safe opioid prescribing.
Additional Resource:
- Hudspeth, Randall. Pain management & opioids: a patient centered approach. Talk presented at: American Association of Nurse Practitioners National Conference; June 2025. Accessed June 12, 2025. https://www.aanp.org/events/national-conference
TRANSCRIPTION
Randall Hudspeth, PhD, MS, APRN-CNP, FAANP: My name is Randy Hudspeth. I am a certified pain management nurse practitioner. I have been in pain management practice for more than 20 years. I have a research PhD and I have done quite a bit of pain management research. I represented AAMP on the core safe opioid prescribing group for a number of years and I have routinely presented at AAMP on this topic. Last year I was the editor of the JMP's special edition on opioid use disorder. And I've been able to publish two textbook chapters on treating pain and OUD so I hope you enjoy the presentation and feel free to ask me or email me or contact me through AANP with any questions you might have.
Consultant360: What are the main themes of your presentation?
Dr Hudspeth: Well the talk has migrated over the years away from people who are solely in pain management practices or addiction recovery, medicine, those kinds of things. More to focus on educating people who are in primary care. And the reason for that is because in the 16 years that we've been focused on this work, we've seen a migration away from patients being seen in pain management practices. And although there are still a lot of pain management practices around and people practicing in that area, a lot of them have closed practices, they have full patient panels. So a lot of patients are migrating into primary care and the academic programs preparing new nurse practitioners don't always have a robust component that talks about the essentials for treating chronic pain patients or even sometimes acute pain patients.
And the second thing we've seen is the idea that there's a focus from the federal government on providers who prescribe opioids. So a lot of providers have opted not to on their control substance licenses so that they just don't even have the opportunity. And patients then are going from primary care to primary care looking for that. So we want to educate people how the system has evolved over the last 15 years, the safety standards that are nationally vetted standards, what people need to know to be safe prescribers, and talk to them about the process of treating a pain patient.
And the process starts with, you know, an appropriate assessment and screening of the patient, a pain focused history and physical exam, a lot of clues of history that talks about background, family living, experience with socioeconomic groups that are involved with misusing medications, those kinds of things that can provide clues to the provider that they might not otherwise think about. And then a pain-focused MP or a physical exam that says do you really exhibit the problems that you're expressing of why you need a pain medication and then explain that the next phase in the process is the trial of an opioid that you know it's not a marriage it's not lasting forever we're gonna give you a pain med it's gonna last maybe for acute pain.
This is maybe only going to be five days. The CDC has great guidelines on those kinds of things and the current research that's out there shows that patients have done quite well on lesser amounts of opioids being prescribed than they had in the past. So that once the trial of an opioid and what the components are of a trial in terms of the necessary components of a patient provider agreement, which used to be called a pain contract. And then a newer recommendation is to have a informed consent for each of the drugs you're giving, because that helps document that you've had the discussion with the patient about the risks, the benefits, some of the barriers that might need to be overcome, and that the patient signs what they've understood and have participated in the decision-making process.
A lot of people don't use the informed consent yet, but that is one of the new national standards. And then finally, the long-term plan. How do you manage the patient over a period of time that is having chronic pain. And when might you look at decreasing the pain med dose? What are the indicators? At what point might the patient need to be changed from one drug to another? And there are some surprisingly new drugs that have different pathways that are on the market that have just been approved, which we'll describe. So we'll give a little bit of pharmacology update on some of that.
This program would meet, it's a three hour program, so it would meet three hours of the required eight hours that the DEA now has for DEA licensure renewal. So it's a really, it's a long-term program, it's a mainstay program at AANP, and it really has changed over the years. We've educated thousands of providers who come to this program and have always, luckily, had really good background and feedback, and we've had a lot of very informative discussions and a good Q&A program. So that's kind of the overall synopsis of the program.
C360: You've been involved in writing the national standards of safe opioid prescribing. Could you walk us through how these standards have evolved over the past 15 years, and what's been most challenging about keeping them current?
Dr Hudspeth: Well, the challenges haven't really been too bad. The initial work was to pull all of the people who had standards developed together so that there was a common framework. That work evolved maybe in the first five years when the CDC investigators first started linking the high number of opioid overdose deaths to the high number of legal prescriptions that were being written. And then there was a time when there was a perception by providers that Big Brother was looking and people were being identified as not following any of the guidelines. But the guidelines for each of the organizations were not necessarily in sync.
So the organizations themselves came together and part of this was funded through the CDC and the FDA who required drug companies, pharmaceutical companies to provide money for REMS education, which is risk evaluation mitigation strategies. And that money went to support educating providers across the country. And different groups wrote project reports and were funded to provide education, AAMP being one of them. And the core group that they worked with was made up of representatives of all different disciplines--physicians, pharmacists, PAs, MPs--as well as representatives from some of the major pain organizations.
So coming together and everyone agreeing that there would be this process of looking at validating just step one in the assessment phase, validating the current tools like the opioid risk tool. And then over time identifying that maybe that tool needed to be updated, which it was at times, that people maybe didn't need to have as much pain med as they were commonly being prescribed. And so what would the process be for tapering down and how would you educate providers to taper down? And what would the proper taper be?
So research was funded that showed commonly, at that time, there was an MME, Morphine Millequivalent Dosage, of about 120 MMEs. And it was determined that probably patients could do better on less. And so a standard of 90 MMEs was developed. And MMEs became a real benchmark for measurement that everyone uses. And now you can even see the MME automatically calculated on the report that comes from the Board of Pharmacy on prescribing for control drugs. And it will show you what the MME is. So you can know that you need to target. And patients did well with 90 compared to 120. And now we think they might do just as well at a lower level even. So there is some discussion currently at lowering the 90 MME, hasn't been officially done yet, but it certainly is out there being researched.
The other thing that was overcoming barriers. So a big one was the PDMP, which is the prescription drug monitoring program, which monitors all of the control substances that are prescribed and pharmacies report this in. In early days, you had to be licensed in your state and you could get a permission and a login to access the PDMP for your patient. And over time, identified problems with that where that me as the provider, I might have 15 to 20 minutes for an interview and it's taking me five minutes to log this in and get it so we were able to get surrogates to be appointed so states approve that you could have a couple surrogates look this up so your office staff could maybe run your PDMP for you. And then you just have to read it and analyze it yourself.
Then there was the cross-border into other states. So if you were in a border community like me, I couldn't always access the PDMP in my neighboring state unless I applied and got permission in that state. Or, and sometimes that required me to be licensed in that state. So that barrier had to be overcome and we were able to get through a compact relationship like our driver's license where you can drive from one state to the other, you can now check the PDMP in your bordering state. So there's a compact relationship there.
And then the PDMP was extrapolated to include other content like the MME measurements and stuff. So that has been a major effort to get that done across the United States. And that has really helped providers to assess what's going on with patients, especially because so many of us are in border states and the laws are different in every state, but we can get the information. So that was a big evolution.
Then providing prescribing information and how to safely prescribe opioids and what the standards would be for the chronic pain patient versus the acute pain patient versus the substance use disorder patient—developing those standards in those education programs and developing certification examinations that would show that providers can demonstrate a competency in those. Those things have all happened because of the focus that has gone on and in the last quarter, amazingly, opioid deaths have continued to increase. There's no doubt about that, but those are not really prescription opioid deaths that are the major cause of that increase. It has been the illicit use of carfentanil coming across the border.
And just educating providers the difference between the fentanyls, you hear fentanyl is a big problem. So I've had patients that are perfect candidates to have a fentanyl patch, especially if they have cancer, an issue like that, but they don't want it 'cause they hear this. So you have to educate the providers to say, explain the desert between pharmaceutical fentanyl, sufentanil, which is a short-acting fast term fentanyl, probably most commonly used in OB because it's got such a short half life and it's very effective. And then the carfentanil, which is the illegal drug that's mixed in with all these street drugs. So no one is prescribing carfentanil. Very few people are prescribing sufentanil. So regular fentanyl that's given for long-term chronic pain is a whole different story, so making people feel comfortable about those particular issues.
Being able to understand the differences between the different mixtures of say oxycodone, oxycodone that is mixed with acetaminophen, less chances of misuse or making that a valuable commodity on the street versus just straight oxycodone. Those kinds of things, just talking to people about that. And the drug families, mixing drug families, hydrocodone versus oxycodone versus morphine versus drugs like hydromorphone or fentanyl, just to talk to them about what's the appropriate drug to begin with and the lowest possible dose and the least problematic drug, how to start and what are the signs that you need to either maybe titrate up, change the drug or titrate down or hopefully the patient gets well and recovers from the problem and the drug can be discontinued and the patient be discharged from being treated for pain management.
So those are the kind of process things that the presentation talks about. And along the way, we also include, you know, a little bit of physiology about pain and the receptor sites and the different mechanisms, the different drugs that some impact the GABA receptors, some impact the receptors. There's a new short-term drug for acute pain that doesn't do either one of those receptor sites but is a sodium channel blocker. So that's a whole new technology that's come out, it's been approved. So we hit on all of those things.
So physiology, anatomical changes you can see with chronic pain, what to look for when you're doing physical exams, as far as needle tracking, where to look for what you might see, screening tools, how to use them, how to document their outcome, how to document that you've done something with the data you've collected. And then the process of how to treat patients, respectfully, and firing a patient from your practice isn't the number one thing to do when patients misbehave because there will be those patients who don't follow the rules and your first challenge is what strategies can you use to bring them back into compliance versus just firing them and moving the problem on to some other provider that gets blindsided by the case.
C360: What are the practical takeaways from your presentation that you want clinicians to leave with?
Dr Hudspeth: The thing I really hope and what we do in the summation phase, and this is a long program, it's a 3-hour workshop. We did it for two hours in the last couple of years and we found that just really wasn't enough, especially because there were so many questions and answers. But basically, if people can put the process in mind. The patient comes in. So this is your assessment phase. You need to be ferret out all the information you can from that patient and use the appropriate screening tools. Evaluate those tools. What might be the appropriate tools to use versus a tool that would be used later when patients are already taking pain meds for a long time. So assessment is number one.
Then you decide that the pain is legitimate and you're going to treat it. But you don't know exactly what would be the most effective treatment. So this is the trial of an opioid phase. So you're going to give them what's required during the trial. Well, you have to give them a consent form. You have to get a PPA in place. You have to explain what's going on, you have to get your baseline urine drug tests done. So you know that they're, they're, they're clean to start, or maybe they aren't clean, you know, and how do you deal with that?
Then you, you move through the trial and the trial can last, you know, up to 90 to 120 days easily. And you might change the drug during that time, feel comfortable changing the drug, up the dose, down the dose, change from one drug to another, maybe you start them on hydrocodone and that really isn't going to be effective. Or maybe you're treating a patient that has rheumatoid arthritis and they might not need, another drug might be some type of a nonsteroidal, might be more effective for them or like an and type of drug or something like that.
So then you move through the trial, once you've got them stabilized, how do you manage them on the maintenance phase? How frequently do you do the urine drug testing? How frequently do you need to see them? Can you give them a 90-day prescription or do you need to do a 30-day refill and see them in the office? What are the components of that?
And finally, under what conditions should the patient be terminated from the practice, the last thing, not as necessarily as a punitive measure. Hopefully, they've reached the curative stage and they can move. But there are times when you do it as a punitive measure. And how do you protect your own practice? And what is the safest way to do it? And how can you treat the patient? What are your requirements and your responsibilities to the patient you've been treating if you decide to terminate them. Usually there's a time that you give the patient to transition out of your practice and seek care elsewhere.
And then additionally, how can you best gain support in your practice by establishing a relationship with a regular pharmacy that you can use. Establish a relationship with a certified pain management provider in your community so that those are really complex and hard patients, you can either refer them to them or you can at least call them and get a telephone conversation going and get some advice.
So those are the kind of things that we want. We want people to feel comfortable treating patients and not that these patients are unwanted in their practice and they would want to turn them away. We want them to feel comfortable to have the basic skills and to know what their limits might be and how to overcome those barriers.
C360: What do you see as the biggest gaps in current knowledge when it comes to safe opioid prescribing and opioid use disorder management? And are there areas you think more research is urgently needed?
Dr Hudspeth: Well, I don't know about more research 'cause there's quite a bit of research that is going on and some really good stuff has been published and we've done quite a bit of publication within AAMP. A year ago, we had a whole journal of the Journal of Nurse Practitioners focused on treatment of substance use disorders, all of them, there are like 10 of them and opioids is just one of 10 opioid use disorder.
Have the didactic content presented in their programs so that when they graduate and they become licensed and they go into clinical practice, they're not treating pain by the seat of their pants that they, that was the way it was done in the old days. But even when I graduated, we didn't really have that. And you came out and you learned it from your peers. And they learned it from their peers. And so trial and error.
And so today there is a concrete body of knowledge that needs to be presented. And if they don't have that in their program for whatever reason, there are programs that they need to go to and access. And there's a lot of online programs, either through the professional organizations of the different practice types, or from the focus groups like the pain societies, the, you know, there's the focus groups, headache pain is treated a lot different than rheumatoid arthritis, neuralgia pain, you know, chronic back pain is a big one. I mean, fibromyalgia, there are guidelines.
And that's what I want them to get them the main takeaway. You probably won't have this coming out of school. You need to go and seek it out. And we give them a nice syllabus to go and look at those different kinds of things. And we highlight the recommendations from the CDC that talk about acute pain, dental pain, chronic back pain, short-term nosioceptive pain from like cutting your finger or a burn or something like that versus chronic pain conditions like rheumatoid arthritis or headache pain, fibromyalgia, those kinds of treatments.
So I want them to have a good handle on where to get the resources. If they don't have them or know them at their fingertips, they can go and look them up. I just want to say that this is an ongoing presentation. We've presented this every year for the last 15 years at AAMP, as well as a lot of state organizations across the country. And PA groups and physician groups also present the same content. So it is available out there in a variety of access points, especially on the internet and the web.
So if people don't get the opportunity to spend three hours in a workshop like this, those resources are available and they should access them and I encourage people to access them. And even when they take the program and get the CE for it, it's a good idea to go back for a little refresher because this data is updated on an annual basis. And it's based on the FDA's blueprint on safe opioid prescribing. And for the first time, I just read that in the last quarter, for the first time in years, the number of opioid deaths decreased in the United States.
So I think we're having some impact either in the illicit drug trade, or in better education of providers who are limiting the number of opioids they're putting out on the market that can be mismanaged or misused.