The Pain Relief Network

Oct 29, 2009
By Carrie Johnson
Washington Post Staff Writer

Heightened efforts by the Drug Enforcement Administration to crack down on narcotics abuse are producing a troubling side effect by denying some hospice and elderly patients needed pain medication, according to two Senate Democrats and a coalition of pharmacists and geriatric experts.

Tougher enforcement of the Controlled Substances Act, which tightly restricts the distribution of pain medicines such as morphine and Percocet, is causing pharmacies to balk and is leading to delays in pain relief for those patients and seniors in long-term-care facilities, wrote Sens. Herb Kohl (D-Wis.) and Sheldon Whitehouse (D-R.I.).
The lawmakers wrote to Attorney General Eric H. Holder Jr. this month, urging that the Obama administration issue new directives to the DEA and support a possible legislative fix for the problem, which has bothered nursing home administrators and geriatric experts for years.

The DEA has sought to prevent drug theft and abuse by staff members in nursing homes, requiring signatures from doctors and an extra layer of approvals when certain pain drugs are ordered for sick patients.
The law, however, “fails to recognize how prescribing practitioners and the nurses who work for long-term care facilities and hospice programs actually order prescription medications,” Kohl and Whitehouse write. They conclude that delays can lead to “adverse health outcomes and unnecessary rehospitalizations, not to mention needless suffering.”

Most nursing homes do not have pharmacies or doctors on site, adding to delays for patients who fall ill late at night or in transition from a hospital.

Justice Department and DEA officials had no immediate comment. The DEA sent out guidance last summer in response to some of the pleas, but it did not resolve the central issue of whether a nurse could serve as an agent of a doctor and administer pain medication with a verbal directive rather than a written prescription from a doctor.
The problem took on new urgency this year after the drug agents heightened their enforcement of the rules at pharmacies in Ohio, Michigan, Wisconsin and Virginia. The pharmacies face tens of thousands of dollars in fines if they deviate from strict controls that require doctors to sign paper prescriptions and fax them to a pharmacy before a nurse can administer them in the nursing home setting.

“The system is broken. It isn’t working, and patients are suffering,” said Claudia Schlosberg, director of policy and advocacy for the American Society of Consultant Pharmacists. “While we need to ensure there are proper controls on the medications, the overall law enforcement concern has to be compatible with meeting patients’ needs, and right now it’s not.”

Doctors in nursing homes say the restrictions do not take into account that many more patients, with higher levels of illness and pain, are moving into long-term-care sites and out of hospitals.
William Smucker, medical director of the Altenheim Nursing Home in Ohio, said that the “delay is not what I would want for myself or my family, and it’s not the way I practice in other settings.”
Terence McCormally, a doctor who cares for patients in nursing homes in Northern Virginia, said the tug of war reflects “the tension between the war on drugs and the war on pain.”
“For the doctor and the nurse, it’s a nuisance,” he said, “but for the patient it is needless suffering.”

http://www.washingtonpost.com/wp-dyn/content/article/2009/10/28/AR2009102803146.html?utm_source=The+Freeman&utm_campaign=26e0b19fdd-In_brief_10-20-2009&utm_medium=email

Medical News Today
Oct 27, 2009

A new Pain Medicine Position Paper published by leaders of the American Academy of Pain Medicine (AAPM), reveals businesses lose $61 billion annually due to ineffective pain care and the lack of optimal pain care delivery. Leaders from the organization are now implementing and teaching a new, “population-based” approach to delivering care with the goal of alleviating pain so patients can get on with their lives.

AAPMedicine’s President Rollin M. Gallagher, MD MPH comments, “Pain affects everyone, and for many millions, pain becomes chronic, a scourge that affects every part of their lives–their work, their hobbies, their friendships, their families, their sex, their fun, their finances, their mood, and even their fundamental sense of identity, who they are. According to the National Institutes of Health, pain is one of our most important national health problems, costing the American public more than $100 billion each year in health care, compensation and litigation. The AAPMedicine’s Position Paper offers solutions that will fundamentally change the way pain is approached in the health care system. The Paper proposes a population-based approach to pain management that will both improve the competency of the health care system to manage pain for the millions of patients suffering needlessly in hospitals with acute pain and on into their lives with chronic pain, and will also reduce the cost of pain to our society. People will be able to work who couldn’t work before. People who work will work longer, better and more productively. People with terminal cancer will die in comfort, preserving their personal dignity and mitigating the emotional suffering of their families. The Proposal is consistent with the medical home approach being fostered as a solution to the problems besetting our health care system, an approach that emphasizes patient responsibility, early effective treatment, and when pain becomes chronic, competent longitudinal treatment, what we call ‘chronic illness management’.”

A population-based approach to pain includes stepped care that is designed to deliver timely access to levels of care that are needed to prevent chronic pain from beginning, or when pain persists, minimizing morbidity through effective care:

Step One: Prevention of disease or injury with the use of evidence-based self-care, such as diet, exercise, ergonomics (alteration of work activities) or cessation of smoking and other drug abuse to reduce the risk of injury or disease.

Step Two: If self-care is not working, patient will then visit their primary care physicians for evaluation and management using evidence-based algorithms.

Step Three: If disabling pain persists, the patient will be referred to a pain medicine specialist who will collaborate with a team of providers, including, nurse case managers, psychologists and physical therapists.

Step Four: If the patient remains in disabling pain, he or she will be referred to a pain medicine specialist within a subspecialty of care.

Currently there is no unified organizational model of pain medicine, which has led to ineffective and fragmented pain care with poor outcomes and higher costs than necessary. This fragmentation threatens patient safety and causes the passing of a patient from doctor to doctor for a diagnosis and pain treatment, even though that doctor may have had minimal or even no specific training in chronic pain management. The Academy believes one of the solutions to this complex problem is the establishment of Pain Medicine as a recognized primary medical specialty. This recognition would allow Pain Medicine’s specialized knowledge, education, training, and multidisciplinary approach to provide standardized training for all physicians and integrated and comprehensive pain care to millions of Americans suffering with acute, cancer and chronic pain.

One segment of society that has carried the burden of an ineffective pain care delivery system is the business community. It is estimated to cost $61.2 billion annually in lost productive time. The majority of this cost (76.6%) is attributed to reduced performance while at work, not work absence. During the course of two weeks, 13 percent of the total workforce experienced a loss in productive time due to a common pain condition. An estimated 3.8 billion hours of work are also lost annually due to pain.

As the largest purchasers of healthcare, businesses have much to lose from ineffective pain treatment of their employees. Finding a unified approach to pain medicine is critical. Back pain alone cost businesses $19.8 billion in lost productive time, with almost three-quarters of the cost attributed to complications of back pain from the lack of proper care.

“The ineffective treatment of pain results in an escalating cascade of health care issues. Acute pain that is not treated adequately and promptly results in persistent pain that eventually causes irreversible changes in the brain and spinal cord. This is referred to as neuropathic pain, a neurobiological disorder that is difficult to diagnose and manage. Persistent pain of this nature often results in further bio-psycho-social changes, which in turn result in further pain and increasing disability. This vicious cycle transforms a human being into a patient who unwittingly becomes a burden to himself, his family and society at large. The emotional, societal and financial costs are immeasurable,” according to AAPMedicine’s Executive Medical Director, Philipp M. Lippe.

Currently there are not enough pain medicine specialists to treat back pain and other pain conditions, and the system for training physicians in the discipline of pain medicine remains insufficient. The Academy’s solution calls for better residency training programs in pain medicine, which will lead to better and more cost-effective pain care.

Recognizing pain medicine as a primary medical specialty would also increase federal funding into pain research. As the population ages, there will be an increased need for physicians who have both specific expertise in pain medicine and broader training in the needs of an aging population. An increase in federal funding for pain research is critical to keep pace with the growing problem of pain in America.

Taking these steps will also improve health care coverage for pain care. Insurance companies often refuse to cover pain-relieving treatments, and access to pain rehabilitation is non-existent in many parts of the country. The Veteran’s Affairs’ medical system has recognized the need for change in pain care and now requires VA health care institutions to provide organized pain assessment and management. Developing an optimal system of pain care delivery would not only address better healthcare for the millions of Americans in daily pain, but its benefits would filter down to both businesses and society. Safe, effective and affordable pain treatment is possible, and the benefits are immeasurable. Click here to view the Pain Medicine Position Paper.

About the AAPMedicine

For more than 25 years, the American Academy of Pain Medicine (AAPM) is the premiere medical specialty society representing more than 2,200 physicians practicing in the field of comprehensive pain medicine.

Source: American Academy of Pain Medicine

http://www.medicalnewstoday.com/articles/168771.php

KATE BENSON
Oct 19, 2009

AUSTRALIA could become the first country to recognise chronic pain as a disease in its own right, giving sufferers greater credibility and access to more integrated services.

Chronic pain, which affects one in five people and costs the economy about $34.4 billion a year, is the third-most expensive health problem in Australia but most sufferers were still seen as malingerers or drug seekers by general practitioners and busy emergency department staff, the pain specialist Michael Cousins said yesterday.
Professor Cousins, the director of the Pain Management Research Institute at the University of Sydney and Royal North Shore Hospital, has led a national draft strategy to have pain management addressed as part of the Federal Government’s national health reforms.

The strategy, now open for public consultation, calls for a national advertising campaign to destigmatise chronic pain, a Medicare item number allocated to better evaluate its prevalence and costs, and a new system in hospitals where pain is included as one of the vital signs assessed by nurses.
“All patients in hospital should be asked what level of pain they are experiencing on a scale of 0 to 10,” Professor Cousins said.

“We take a patient’s temperature to see if they have a fever, so we need to be asking them to rate their pain as well. That’s the only way we will know to treat it and see if it is improving.”
The strategy also calls for standardised assessments, phone hotlines for sufferers and their carers and a centralised website with links to services, information and resources. It wants funding for consumer groups, an ombudsman for personal injury insurance and pain management included as a core skill in undergraduate and postgraduate courses for doctors, nurses and allied health workers.

Management of chronic pain, where a sufferer experiences daily pain for three months or more, was “shockingly inadequate” because it was still seen as a symptom of another condition rather than a problem in itself, Professor Cousins said.

Many pain management clinics in Australia now had waiting lists of up to three years, and GPs were often reticent to prescribe large amounts of opioids or use newer methods of pain relief such as channel blockers, leaving sufferers with little help, he said.

“Pain is one of the biggest health issues in Australia today – every bit as big as cancer, AIDS and coronary heart disease. It affects a person physically, psychologically and environmentally; and destroys all aspects of individual and family activities.”

The chairwoman of the National Health and Hospitals Reform Commission, Christine Bennett, said the “scale, impact and cost of chronic pain is so alarming that it warrants a co-ordinated, national approach to address this major health issue”.

A final version of the strategy, the result of thousands of hours’ work by more than 70 specialists, will be presented at the National Pain Summit in March and could see reforms put in place by the end of next year.
“Chronic pain is costing us billions but half those costs could be saved if a strategy like this was implemented. It’s almost a no-brainer,” Professor Cousins said.
Source: smh.com.au

http://www.brisbanetimes.com.au/national/recognition-on-way-for-sufferers-of-chronic-pain-20091018-h2zq.html

Oct 14, 2009
Bill H. McCarberg, MD
Question

The primary care physician is the point of service entry into our medical delivery system. This doctor is the one initially seen for almost every type of disorder. Why is our opioid policy so restrictive that most primary care physicians will not touch the needs of patients with chronic pain? This places an extreme burden on a dwindling number of chronic pain specialists.

Response from Bill H. McCarberg, MD
Assistant Clinical Professor, Department of Family Practice, University of California San Diego School of Medicine; Founder, Chronic Pain Management Program, Kaiser Permanente, San Diego, California
The primary care physician is usually the point of service entry into our healthcare system. This could be the family physician, internist, osteopath, pediatrician, gynecologist, or a variety of physician assistants and nurse practitioners. The initial work-up occurs at a primary care facility, and treatment is rendered. In most acute problems, with the help of the providers and the natural healing process of the body, the symptoms resolve. When the problem continues despite appropriate interventions or the condition is persistent (eg, diabetes, congestive heart failure), continuing care and management usually occur at the primary care level.
Seventy percent of patients with acute pain do not seek medical attention; the delay often results from the hope that they can manage the pain on their own.[1] Moderate to severe pain is still one of the most common reasons for primary care visits in the United States.[2,3] In a 2008 survey, more than 1 in 4 Americans reported an episode of pain during the previous year.[1] Acute pain is a protective, biological process resulting from trauma or injury to tissue, usually of rapid onset and limited duration with an identifiable source.[4,5] Acute pain is prevalent, resulting in disruptions in activities of daily living, work absenteeism, and reduced productivity.[1]
Inadequately treated acute pain also may lead to adverse physiologic changes, including cardiac dysfunction, impaired immunity, and the development of chronic pain.[6] Increased activity in peripheral and central nociceptive pathways can lead to plastic changes in neural circuits that perpetuate such acute pain symptoms as allodynia (painful responses to normally nonpainful stimuli) and hyperalgesia (increased sensitivity to painful stimuli), often after the initial insult has resolved.[7]
Pain remains undertreated, especially in the primary care setting. Even when patients make the decision to visit a healthcare professional, inadequate training and resources may prevent proper assessment of their condition.[2] Deficiencies in pain management related to patient gender, race, and socioeconomic status have been reported.[8]
The treatment of pain varies according to the cause. Determining the underlying problem and resolving the condition are usually adequate to treat acute pain. In persistent pain, lifestyle changes, medication, and adaptation are frequently needed. In both of these circumstances, opioids can be a valuable option. For any of us who have suffered with pain, the efficacy of opioids cannot be underestimated. The contribution of opioids to improved function, sleep, mood, and pain has been demonstrated in multiple trials.[9] Yet reluctance to use opioids in primary care is increasing.
Over the past 3 decades, there have been changes in opioid prescribing in the United States. With the establishment of pain medicine as a specialty and more understanding and knowledge about the mechanisms of pain, vast improvements were seen in patient comfort, acute pain recovery times, and functional improvements.[2] Observing a continuing unmet need in pain management, state medical boards developed intractable pain acts to encourage all providers to manage pain more effectively. Texas passed the first such act in 1989.[10] By following the guidelines stated in the intractable pain acts, providers were protected from state medical board sanction when prescribing opioids. Several states developed similar acts, and then the Federation of State Medical Boards created Model Guidelines for the Use of Controlled Substances for the Treatment of Pain. In 2004, these guidelines were updated to a Model Policy. Twenty-eight state medical boards have adopted the Model Policy verbatim, and 10 other states have adopted guidelines with similar language.[11]
Despite these advances, primary care physicians are increasingly hesitant to prescribe opioids. Reasons for this reluctance include compliance with treatment, the possibility of adverse effects or abuse related to analgesic medications, limited access to interdisciplinary care, and perceived regulatory scrutiny.[12,13]
As the therapeutic use of opioids has increased in recent years, so too has the misuse and abuse of these agents.[14] This has contributed to concerns among some clinicians and patients that opioid therapy will lead to addiction among pain patients,[15] although only a small percentage of pain patients actually develop iatrogenic addiction.[16] Some of this confusion may stem from inconsistent use of the terminology associated with opioid use, abuse, and addiction. Critical for understanding patient responses and behavior is recognizing the differences between such terms as addiction, dependence, and tolerance, which will lead to the development of appropriate treatment and referral plans.[17]
The public health is not best served by decreasing the medical use of opioids even with increases in prescription opioid misuse and abuse. This highlights the need for examination of the potential for inappropriate medication use as part of an individualized risk-benefit analysis that should be conducted for every patient being considered for opioid therapy. Risk for aberrant drug use depends more on genetic and psychosocial factors, including personal and family history of drug abuse, the presence of psychiatric disorders, and a potential patient agenda for euphoria and abuse, rather than the mere exposure to an opioid.[18]
The majority of patients who present to their primary care provider will be considered low risk and can be managed routinely in this setting.[19] Others with a known past history of substance abuse, or a psychiatric disorder may require consultation or referral to an appropriate specialist. Such an approach benefits the patient, the prescriber, and society as a whole by making this essential analgesic class available to patients in pain, while reducing the risk associated with the prescribing of opioids.

http://www.medscape.com/viewarticle/710440?src=emailthis

Sep 22, 2009
by SB. Leavitt, MA, PhD
Controversy still exists about the long-term prescribing of opioids for chronic noncancer pain (CNCP) conditions, and particularly regarding the safety and effectiveness of higher opioid doses. Yet, there appears to be a subset of patients with CNCP who require and thrive on ultra-high doses exceeding morphine-equivalent opioid doses of 1,000 mg/day — demonstrating that what some practitioners might consider as being way too much opioid is just the right amount for certain patients. However, careful patient management is necessary according to a recent journal article.

Writing in the September 2009 issue of the journal, Practical Pain Management, Jennifer Schneider, MD, and colleagues note that patients requiring high doses of opioids are usually quite ill and impaired due to their chronic pain, often bed-ridden or house-bound, and withdrawn from socialization for a considerable period of time [see reference below for article access]. While some observers and published guidelines have claimed that morphine-equivalent opioid doses greater than 200 mg/day are ineffective, there is no evidence from good-quality clinical trials to support such claims. Schneider et al. emphasize that there is no maximum safe dose of opioids and there are wide variations — as much as a 40-fold variation — in the dose required to achieve patient comfort and function without causing sedation or physical impairment.

The authors propose classifying morphine-equivalent doses of 200 mg/day or less as “low or standard dose,” 201 to 1,000 mg/day as “high dose,” and greater than 1,000 mg/day as “ultra-high dose.” Often, multiple opioid formulations are required at the ultra-high level, including (a) daily regimens of sustained-release or long-acting opioids to help control baseline pain, (b) short-acting or immediate release opioids taken “as needed” for flares or episodes of breakthrough pain, and (c) for breakthrough pain that quickly reaches maximum intensity, a rapid-acting opioid (eg, fentanyl lozenge or sublingual oxycodone) may be needed briefly. Morphine-equivalents of all opioids taken each day are combined to calculate the total dosage.

The authors do concede that patients taking ultra-high doses require extra care, and extra time by practitioners, and they recommend a number of important management strategies (see Table 3 at right from the article). As one strategy, urine drug testing (UDT) is recommended; however, they caution that practitioners must understand the limitations of UDT and potentials for misleading results. Furthermore, quantitative analyses of drugs in urine cannot be used to assess therapeutic compliance, since such measures vary depending on individual metabolism and when the opioid was taken in relation to when urine was collected.

It is essential to establish with patients, and their families, realistic goals and objectives of opioid therapy. These might include 30% to 50% pain relief, elimination of bed- or house-bound days, cessation of emergency room visits, or a resumption of favorite activities and social interactions. Improved functionality is as important a goal as pain relief. However, the authors note, “…there is no necessity to ever lower or cease opioid treatment if the patient’s pain and function are significantly improved and the patient is tolerating the medication well.” Many patients reach a plateau dosage after titration and remain at a relatively constant dose range, albeit ultra-high, for years. “It is a myth that tolerance to the pain-relieving effect of opioids is to be expected,” they write. Increased pain after months or years is more likely due to progression of disease rather than late-developing opioid tolerance.

Commentary: While Schneider and coauthors recommend involving the patient’s family, if possible, one area not discussed is counseling patients and their caregivers on handling opioid emergencies; that is, recognizing overmedication and overdose, and what to do if these occur. This could be especially critical when high doses of opioids, or dose increases, are prescribed and before opioid tolerance has developed. Also, at any time there could be metabolic interactions with newly prescribed drugs causing an unexpected increase in opioid serum levels (with the exception of morphine, hydromorphone, and oxymorphone, opioid analgesics are metabolized via the same CYP-450 liver enzymes as many other drugs). And, when a patient is allowed “as needed” opioids for flares or breakthrough pain there could be periods of some overmedication depending on frequency of administration or how the patient metabolizes the analgesic. Practitioners may feel more comfortable in prescribing higher opioid doses if they know patients and caregivers are educated on appropriate safety procedures in the event of unanticipated overmedication or accidental overdose.

Reference: Schneider J, Anderson A, Tennant F. Patients who require ultra-high opioid doses. PPM. 2009

http://updates.pain-topics.org/2009/09/ultra-high-opioids-when-too-much-is.html