Category Archives: President’s Notes

Thrown Off the Pendulum

by Mordecai Potash, MD

In the two years that have passed since the CDC Opioid Guideline was released, many pain management thought leaders have conceptualized this guideline as a pendulum that was to swing patient care from an extreme of opioid permissiveness to a more thoughtful middle-ground of opioid allowance within limitations. That middle ground was supposed to permit opioid prescribing in chronic pain for well-selected and well vetted patients whose dosing is within reasonable limits. After all, the CDC guideline’s authors made it clear that they were not trying to create a new standard of care in pain management, but instead give clinicians recommendations to make their own clinical approaches to pain management treatments safer and more effective.

However, there are several recent publications to suggest that – far from finding a balanced middle ground – the pendulum has swung abruptly in the opposite direction with patients being thrown off long-established opioid treatments because of providers’ stark fears and frustrations.

In a ‘Perspective’ published in the New England Journal of Medicine, Dr. George Comerci and his colleagues at the University of New Mexico reported that their interdisciplinary pain service has been inundated with patients who were compliant with their pain medicine treatment for years or decades but had their lives thrown into turmoil when their doctors abruptly adopted strict “no opioid” policies [1]. The article also pointed out that even when physicians are willing to continue to prescribe opioids for stable patients, health insurance companies require a mountain of prior authorization paperwork to be filled out for these patients.

In my own outpatient practice, I have encountered – and spent countless hours – filling out these cumbersome prior authorization forms. By taking between 45 minutes to one hour per form, what the insurance companies label as a tool to help the prescriber has instead become an onerous burden dissuading providers from continuing opioid treatment.

In another article published in Reason Magazine, Jacob Sullum and his colleagues wrote an amazingly comprehensive description of the many facets of our country’s current opioid crisis [2]. They pointed out that although opioid-containing pain medications has led to misuse or addiction issues in some chronic pain patients, this has not happened nearly as frequently as portrayed in the media. Mr. Sullum pointed to the 2014 results of a survey from the National Survey on Drug Use and Health that suggested that a little more than 2% of chronic pain patients end up misusing their pain medications to the point of substance use disorder. This number is far less than is quoted by Governor Chris Christie, the point-man of the Trump Administration on the opioid crisis. The article also points out that opioid prescriptions have been dropping since 2010, even as opioid abuse has been sky-rocketing with heroin and black-market fentanyl which account for the spike in opioid abuse – not prescription medications.

The Reason Magazine article makes it clear there is some relationship between permissive opioid prescribing and the rate of national opioid abuse. But that the relationship is not a straight-forward one and often depends on other factors such as educational attainment and employment options.

Dr. Sanford Silverman does an outstanding job expanding on these ideas in his newly published article “CDC Guidelines: Be Careful What You Wish For” [3]. Dr. Silverman points out that we are really dealing with two epidemics when we look at what is being called the opioid crisis – there is the epidemic of prescription opioid abuse which has been declining since 2010 and a separate epidemic of illicit heroin, fentanyl, and other illicit opioids which has been increasing dramatically since 2010.

Dr. Silverman points out that the strict regulatory changes affecting states like Maine and Rhode Island – as well as changes in major health insurers like CVS Caremark – will decrease precipitously the number of opioid prescriptions being written for patients but will likely do nothing to combat opioid overdose deaths in the state. What is needed is easily accessible medication-assisted treatment for patients whether they developed addiction from illicit drug use or prescription use. So far, medication assisted treatment remains out of reach for most patients.

Dr. Silverman also points out that the CDC Guidelines were primarily geared for helping the primary care provider dealing with acute pain complaints. This type of patient is very different that the type of patients that we pain clinicians usually encounter. Our typical patient has seen several, if not dozens, of previous pain management providers with mixed success and are often coming to us already on high dose opioid therapy (what Dr. Silverman calls “legacy patients”). If we are to follow the CDC Guideline strictly, we are supposed to reduce the dose of pain medications to 90 morphine milligram equivalents per day. But, for many of these patients, this is not a realistic goal and would present real harm to the patient if attempted. The real question is what can we do for these patients that acknowledges their current treatment regime and response to that treatment while also acknowledging changing standards of care in opioid-based therapy for chronic pain.

Well, I am delighted to tell you that our September annual conference will go a long way in answering the conundrums raised by these three articles – with our conference theme on ‘Balanced Approaches to Acute and Chronic Pain’.

Dr. Silverman will be speaking on the CDC Guideline and the points he raises in his article. Our conference will also feature Keith C. Raziano, M.D., Physicians Pain and Rehab, Sandy Springs, GA, who will be speaking on Maximizing Functional Outcome and Minimizing Chronic Pain. The popular author and orthopedist David A. Hanscom, MD, at the Swedish Neuroscience Institute will be speaking on Solving Chronic Pain with a Self-directed Structured Approach.

As if that isn’t enough, we will also host talks on several other areas including Catastrophic Injury Across the Continuum, and Advanced Techniques in Neuromodulation. Taken together, we have assembled an array of nationally prominent speakers presenting on exciting and practice-relevant topics.

So, I hope that you keep fighting the good fight for your patients, who I am sure appreciate everything that you do for them. I also hope that you plan to join us from September 21st to 23rd at the Sheraton Atlanta Hotel to recharge your batteries, reconnect with colleagues, and learn how excellence in pain management is still achievable even during these trying times!

[1] G Comerci, J Katzman, D Duhigg. Perspective. Controlling the Swing of the Opioid Pendulum. New England Journal of Medicine, published 02/22/2018 and accessed at http://www.nejm.org/doi/full/10.1056/NEJMp1713159

[2] Jacob Sullum. America’s War on Pain Pills Is Killing Addicts and Leaving Patients in Agony. Reason Magazine, April 2018 issue. Accessed at https://reason.com/archives/2018/03/08/americas-war-on-pain-pills-is

[3] Sanford M Silverman. CDC Guidelines: Be Careful What You Wish For. Interventional Pain Management Reports. Volume 2, Number 1, Pages 1-8. Accessed at http://www.ipmreportsjournal.com/current/pdf?article=MTcw&journal=7

 

SPS President’s Newsletter Column – Summer 2017

Hyperbole Over Nuance

by Mordecai Potash, M.D.

One of the ways I like to unwind is to watch HBO on my cellphone or tablet. Whether it’s Real Time, Last Week Tonight, Westworld, or Game of Thrones, I am captivated by HBO’s shows!

One show, VICE – and its online companion, VICE News –  has recently featured several stories that have to do with opioids and pain management. The stories do a great job of capturing the multi-faceted aspects of this issue. They also show how strict and unyielding policy solutions to current controversies in opioid-based pain management can make misery out of the lives of countless people.

Several stories have focused on the state of Maine, since it has one of the highest rates of opioid overdose deaths in the country [1]. One story, enticingly titled “The Men Who Catch Your Lobsters Are Self-Medicating with Heroin”, explored the high rate of heroin and other opioid abuse in the lobster fishing industry along rural, costal Maine [2]. It features fishermen who work seasonably and spend almost all their disposable income on heroin, pain pills, and other drugs. The problem has gotten so bad, that these fishermen commonly encounter replacements on their boats because their previous shipmates overdosed and died. As one fisherman put it in a VICE-linked article:

“On Monday morning, I’ll go to work, it will be me and a guy named Jesse, and then the next morning it will be me and a guy named Mike. I’ll say, ‘Oh, where’s Jesse?’ and they’ll say, ‘Oh, he didn’t make it through the night.” [3]

Once a fisherman wants help for substance abuse, there are huge obstacles to obtaining it. Many live and work in a part of costal Maine that is about the size of Delaware but has a population of only 30,000 people – or about 1/25th the population of Delaware. There are no detox beds at all in the area, so a night in an ER or a couple of days in jail is the closest they get to actual medication-assisted detox services. The closest real medication-assisted program at least a 45-minute drive away – way too far away to accommodate the dawn-till-dusk hours of working fishermen.

VICE is hardly the first program to highlight Maine’s opioid addiction problem. There have been many state and national health reports about its steep rise in opioid overdoses as well as an outstanding ten-part report by the Portland Press-Herald [1].

In response, Maine has adopted some of the strictest opioid prescribing restrictions in the country [4]. One provision mandates that Maine prescribers are not allowed to prescribe more than 100 morphine milligram equivalents (MME) to their patients unless they attest that the patients qualifies under a palliative-care exception. Many Maine prescribers are fearful that, unless a patient is actually dying, they will be prosecuted if they prescribe more than 100 MME. They have told their patients that they are not prescribing more than 100 MME under any circumstances – if they haven’t already totally cut of all their patients from pain medications. Dr. Steven Hull, the Director of Pain Rehabilitation at Mercy Hospital in Portland, Maine, is afraid that many chronic pain patients that were well-managed on opioid-based pain medications will become depressed and suicidal by the cutbacks.

Another VICE story titled “Treated like addicts – The crackdown on opioids has left pain patients suffering with chronic pain and stigmatized” reports on patients whose pain was well-controlled on opioid-based pain medication but are now being cut off from this treatment with horrendous results [5].  It documents one patient whose pain from adhesive arachnoiditis was well-controlled with fentanyl transdermal and oxycodone until her doctor began to prescriber her less and less medication at each visit without explanation. When the patient finally brought it up, she was told that new regulations required the progressive decrease. She says now “My pain is out of control… I mean I can stay alive, but my quality of life has dramatically decreased”.

Like any good reporting, this story also features an opposing viewpoint. In this case, VICE interviews a prominent physician who believes that chronic pain patients are mistaking pain relief with opioid dependence. In other words, every patient that believes he or she has responded to opioid-based pain medications is simply psychologically dependent on them.

The reporter documents that many patients see that doctor’s view as “fueling an anti-opioid hysteria that favors hyperbole over nuance and glosses over the complexities of treating many painful conditions” (my emphasis added). Another patient, who is also a retired physician, adds, “They’re confusing legitimate pain management with addiction. Those are completely separate venues.”

After a year and some changes since the CDC Opioid Guideline was released, we have certainly seen a lot of ‘hyperbole over nuance’ in the rush to stem the tide of opioid overdose deaths. In previous columns, I expressed at least a little bit of hope that these changes would still allow for the practice of opioid-prescribing to well-assessed and well-supervised chronic pain patients who simply do not respond to non-opioid medications. Now, I am not so sure.

This past year, I have informally spoken with many pain management colleagues who are seriously contemplating not prescribing opioid-based pain medications any longer. Some are contemplating leaving pain medicine all together forever and go back to practicing neurology, anesthesiology, or another specialty full-time. To be clear, I am not talking about a practitioner whose training consists of attending a pain conference once or twice. These are fellowship-trained, board-certified pain management specialists who have spent thousands of hours building up their pain management practice. And now, they are giving serious thought to closing down their pain practice for good – or at least dramatically changing it.

I can’t blame my colleagues. Those of us that continue to offer opioid-based pain management services find ourselves being attacked on all fronts.

On the insurance side, several health insurers are requiring oodles of prescriber documentation in order to approve the coverage of any extended release opioid pain medication – even ones on the insurance formulary. I have filled out a couple of these documents recently for my own patients. On each patient, I had to compile a dossier of urine drug screens, opioid agreements, treatment plans, substance use assessments, and other clinical documentation  – requiring about an hour per patient.

On the legal side, pain management specialists are terrified of being investigated or arrested if they continue to prescribe any amount of opioid-based pain medication. And that fear is not without foundation! There have been many investigations and arrests of opioid prescribing physicians, including several in the South [6]. Federal agencies also don’t shy away from declaring that this is just the start of their crackdown. In fact, the FBI very recently sent out a press release titled “Health Care Fraud Takedown – Nationwide Sweep Targets Enablers of Opioid Epidemic” [7].

Given all the heat that’s on us right now, it is no wonder my colleagues are thinking of giving it all up. The professional satisfaction a pain specialist gets when serious pain is made more manageable by opiates does not compare with the panicked dread of worrying about being arrested for providing that humane care.

I certainly hope that this column has not convinced even more of my colleagues to throw in the towel and to just offer trigger points and ESI’s as their sole contributions to pain management. Rather, I hope that it has reaffirmed to those that have been having these contemplations that they are not alone in these thoughts or fears!

Indeed, I think we have done a really good job of organizing our upcoming Southern Pain Society Conference to discuss these topics robustly.

On Friday, we will hear a talk on opioids and abuse deterrent formulations from Dr. Feng Zhang. Dr. Zhang and his team at the University of Texas have been responsible for developing the abuse deterrent formulations used in Oxycontin and Opana and have several new abuse-deterrent formulations in the pipeline as well. Dr. Zhang will undoubtedly explore what role will these abuse deterrent formulations have in stemming the tide of pain medicine overdose incidents.

On Saturday, we will be hearing from Duke University’s Dr. William Maixner. Dr. Maixner is the Director of Duke’s highly prestigious Center for Translational Pain Medicine. He will talk about translational medicine for chronic pain and how that multi-disciplinary, highly collaborative approach is speeding up the development of new treatments for complicated chronic pain patients.

Later on Saturday, we will be hearing from Dr. Hans Hansen – a “fan favorite” from last year’s conference! Dr. Hansen will reflect on the tectonic shifts that have changed the landscape of pain medicine since the CDC Guidelines were released year.

Then on Sunday, we will hear from my friend and colleague, Dr. Arwen Podesta. Dr. Podesta is an expert in holistic medicine, addictionology, and forensic psychiatry and will use these expertise areas to present the latest in the assessment and management of addiction issues in chronic pain.

So, you can see that we – along with our Southern Headache Society colleagues – have put together a program worthy of the multi-faceted challenges we face.

See you in New Orleans!

–Mordi

REFERENCES:

[1] Eric Russell. A deadly epidemic: Addiction to opioids has put an entire generation at risk. Portland Press Herald. http://www.pressherald.com/2017/03/26/lost-heroins-killer-grip-on-maines-people/  Published 03/26/2017

[2] See URL   https://tonic.vice.com/en_us/article/ev43gk/the-men-who-catch-your-lobsters-are-self-medicating-with-heroin

[3] See URL   http://www.pressherald.com/2017/04/02/lobstermen-under-siege-heroin-epidemic-feeds-on-an-iconic-way-of-life/

[4] Marina Villeneuve. Chronic Pain Patients Say Opioid Law Creates New Crisis. The Associated Press. Published on 04/22/2017 and accessed at URL   https://www.usnews.com/news/best-states/maine/articles/2017-04-22/chronic-pain-patients-say-opioid-law-creates-new-crisis

[5] See URL   https://news.vice.com/story/opioids-chronic-pain

[6] See the following URLs for recent local opioid prescriber arrests:
http://www.heralddemocrat.com/news/20170711/fbi-arrests-sherman-doctor
http://www.theadvocate.com/baton_rouge/news/article_d6c70fe8-67f5-11e7-b922-db0d97ccab9c.html
http://www.fox9.com/news/267649616-story

[7] See URL https://www.fbi.gov/news/stories/nationwide-sweep-targets-enablers-of-opioid-epidemic

President’s Message January 2017 – Mordecai Potash, MD

It is my great pleasure to author my first column as President of the Southern Pain Society. In trying to find some inspiration for this column, I went through my New York Times’ collection of articles about chronic pain. I have long been a print and then digital subscriber to the Times, and now have amassed a collection its articles about chronic pain, pain management, and palliative care issues (with thanks to my father-in-law, who dutifully sends to me any article that escaped my eye).

Looking at these articles chronologically, it shows the great arc of change that our field has been through during our professional careers. From one practice standard and swinging to another – pain management as a field and as a professional practice has experienced marked changes and intense scrutiny that few fields of medicine have undergone over the last thirty years.

Just looking at the headlines (not even the articles themselves) will give you a good taste of this:

  • August 26, 1985 – “Helping Families Deal With Chronic Pain”
  • March 28, 1993 – “Patients in Pain Find Relief, Not Addiction, in Narcotics”
  • July 29, 2001 – “The Alchemy of OxyContin”
  • December 21, 2001 – “Few States Track Prescriptions As Way to Prevent Overdoses”
  • November 25, 2003 – “The Delicate Balance Of Pain and Addiction”
  • October 19, 2004 “Doctors Behind Bars: Treating Pain Is Now Risky Business”
  • May 30, 2006 – “Doctors Struggle to Treat Mysterious and Unbearable Pain”
  • March 27, 2007 – “Trafficker or Healer? And Who’s the Victim?”
  • June 17, 2007 – “Doctor or Drug Pusher”
  • August 29, 2007 – “A Surplus of Treatment Options, Few of Them Good”
  • May 13, 2008 – “Back Pain Eludes Perfect Solutions”
  • November 05, 2009 – “Treating the Pain Epidemic”
  • April 09, 2012 – “Tightening the Lid On Pain Prescriptions”
  • May 21, 2016 – “Prescription Dip Seen as Advance in Opioid Battle”
  • March 16, 2016 – “New Standards for Painkillers Aim to Stem Overdose Deaths “
  • November 23, 2016 – “If the Doctor Orders Marijuana, Will Insurers Pay?”
  • December 29, 2016 – “Ethics and Pain: It’s Complicated”

See what I mean? From recognizing that many were languishing unnecessarily due to pain; to beginning to recognize the societal trade-offs that would stem from aggressive pain management; to re-evaluating the legitimacy of providers who treat patients’ pain zestfully; to recognizing that effective pain management treatments are often elusive or expensive (or both); to trying to craft new guidelines to stem prescription abuse; to grappling with the impact of the medical cannabis movement; and to finally recognizing that our field is inherently complicated and perennially chock-full of contradictions.

Many of these articles have the term “double-edge sword” in their text, either as an interview quote or as a journalistic conclusion. This term does capture the dichotomy of our work – the very treatments that can be nearly life-saving for one of our patients can be ineffective for another, or even life-destroying. This dichotomy is true whether our treatments include extended release opiates, nerve blocks, rhyzotomies, kyphoplasties, spinal stimulators, infusion pumps, mindfulness exercises, or any other treatment that we render.

I personally know patients that have had such positive responses to each of these treatments, the word ‘miracle’ tumbles out repeatedly as they describe their response. I also know patients that would describe each of these treatments as having ruined their lives, leaving them even more disabled and embittered than prior to treatment (well, truth be told, I don’t know anyone who would describe ‘mindfulness’ as ruinous – just a hippy-born, navel-gazing, fantastic waste of time).

As we start 2017, the arc of change continues. Many state legislatures and healthcare payers / insurers are considering tremendous regulatory changes in light of both the CDC’s recommendations on opiates for the treatment of chronic pain and the nation’s changing attitudes towards the use of cannabis for the treatment of pain. Several recent articles have suggested a “swap” of chronic opiates for chronic cannabis – suggesting that this would lead to less societal pain such as traffic accidents and overdose deaths [1]. Even as some authors suggest these changes, disturbing reports about dramatic increases in traffic accidents, accidental childhood exposure, intense side effects, and – yes – overdose deaths are appearing in medical [2] and legal reports [3].

I am not “poo-pooing” medical marijuana. Rather – if there is anything the last 30+ years has demonstrated to us over and over again – it is that there are no easy answers in pain management. An approach that may work wonders for one patient may fail miserably in another. What remains the truest ‘answer’ is the ethos that I have seen demonstrated over and over again from our colleagues, in our newsletters, and at our conferences. We treat our patients with zealous compassion, encouraging that they deserve to live a life free of intense daily suffering, and advocating to institutions about preserving and enhancing treatment options for people with chronic pain.

I guarantee you that 2017 will bring new challenges to this ethos. But I also guarantee you that we have together faced similar challenges in the past and that our organization will continue to educate and promote our highest healing ideals.

REFERENCES

[1] Eric Sarlin. Study Links Medical Marijuana Dispensaries to Reduced Mortality From Opioid Overdose. NIDA Notes, published 05/17/2016 and accessed at  https://www.drugabuse.gov/news-events/nida-notes/2016/05/study-links-medical-marijuana-dispensaries-to-reduced-mortality-opioid-overdose
[2] Howard S. Kim, et al. Cyclic Vomiting Presentations Following Marijuana Liberalization in Colorado. Academic Emergency Medicine. Volume 22, Issue 6, June 2015, Pages 694–699
[3] Rocky Mountain High Intensity Drug Trafficking Area. The Legalization of Marijuana in Colorado: The Impact. Volume 2 / August 2014. http://www.rmhidta.org/html/August%202014%20Legalization%20of%20MJ%20in%20Colorado%20the%20Impact.pdf

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