Opioids – Why Patients and Physicians Are Frustrated

Frustrated patient and physicianEvery week there is a new article on the opioid epidemic. The focus is all on the number of people addicted to pain medications and how people are dying every day. Today an article appeared in the paper on how one of the drug companies is making a long acting opioid and how it can make people become addicted. Other stories are focusing on those who already have addiction problems. The real problem is the need for better treatment for pain, for both acute and chronic. 

Chronic pain affects 30 percent of the worldwide population. Until the last several decades, many people did not survive long enough such that pain was a problem for decades of their lifetime. Now, life expectancy is often into the 80’s and many have chronic, painful conditions for nearly half of their life. The range of treatments is limited, and there is often no full cure for a lot of conditions that result in pain, despite the fact that western society expects the physician to have a miracle cure. Even the most knowledgeable patients often have unrealistic expectations to be pain free with the next treatment option.

Patient and Physician Need To Work Together

Yes, the United States of America has an opioid addiction problem. The real problem, however, is a lack of education for the patient and physician on how pain can be treated. On top of this is the focus on treatment of addiction versus the better treatment of pain. One of the main problems leading to opioid addiction is the lack of medications to treat pain. Other treatments for pain are not as easy as taking a pill. Physical therapy, behavioral interventions and injections may be better, but they are more difficult for the patient and definitely more costly.

The most frustrating problem for physicians is insurance coverage for newer medications, maintenance physical therapy, psychological therapies, alternative therapies, comprehensive pain programs and sophisticated interventions. It is easier to get coverage for an opioid for pain than get psychology to prevent the need for opioids. The same is true for allowing a trial of a spinal cord stimulator versus allowing for a back surgery. An intervention that has a cheaper overall cost and is safer within a year or two will not be covered by insurance. Further, the insurance companies often will say a treatment is experimental, such as a radiofrequency neurotomy or the use of Lidoderm patches, refusing to cover the expense while gladly paying for highly addictive opioids.

Pain patients and physicians are equally frustrated by the lack of coverage for alternatives to opioids. Instead of focusing so much on the bad outcomes of opioids and treating addicts, investments need to be placed on using alternative treatments and funding research to develop better pain treatments. One third of the population suffers from pain. It is about time the pharmaceutical industry, government, and even insurance companies invest in better pain management strategies.

Stop Telling These 3 Lies To Your Doctor

Lies We Tell our Doctor Minnesota Chronic PainIf you’re like most Americans, odds are you bend the truth a little once you enter the doctor’s office. While it may seem harmless, lying to your doctor can have serious consequences. We all have unhealthy habits, and none of us are perfect, so we don’t expect you to eat healthy all the time and get 90 minutes of exercise each day. It’s perfectly normal to have some flaws, but when you lie to your doctor about your health habits, it only makes it harder for us to provide you with the utmost care. Here’s a look at three subjects people often lie about, and why that can be problematic.

Falsehoods in the Doctor’s Office

Here are three subjects that people often lie or bend the truth about when the topic is broached by the doctor:

1. Their Symptoms – This is especially true for chronic pain patients, but the reasons behind the lies may be different than you expect. For starters, some people with chronic pain overstate their symptoms because they are fed up with failed treatments and hope the doctor will take their concerns more seriously. Unfortunately, sometimes this leads to over-prescribing or giving harmful doses, which can lead to health issues or dependency. On the flip side, many patients don’t want to be defined by their chronic pain, so they play off symptoms like they are no big deal. This too makes it difficult for your physician to give you the best care. Great doctors will believe what you say and won’t judge you for saying them, so be open and honest about everything you’re experiencing.

2. Their Food Choices – As we alluded to above, nobody sticks to the perfect diet each and every day, and that’s fine. However, you need to be honest with your doctor about your dietary choices. Oftentimes the food we eat can affect how our bodies perceive pain. If you eat a lot of junk food or a heaping helping of spicy options, it can lead to inflammation in our joints, which may make pain worse. If your doctor can pinpoint some food choices that may be impacting your pain, this can help you get a better grip on your chronic condition. However, your doctor is not going to be able to help if you don’t open up about your regular diet.

3. Liquid Intake – Fluids are very important if you want to combat your chronic pain, but only the right ones will do the trick. Dehydration can make pain worse, so you want to make sure you’re getting plenty of water throughout the day. Most people are pretty honest about their water intake, but a liquid they often lie about is their alcohol intake. Alcohol may serve to “numb” the pain in the short-term, but it’s damaging other structures and making pain worse in the long run. Whether it’s out of embarrassment or the idea that their doctor may think less of them if they knew the extent of their drinking, many people skirt the truth when talking about alcohol intake. Your doctor isn’t going to judge you – he just wants to help get your condition under control. If you’re grossly underestimating your alcohol intake, your doctor may overlook that as a potential solution, or it could impact the effectiveness of your pain medication.

In the end, just be open and honest. We’re here to help, not to judge anyone for their lifestyle choices.

Here are the 12 Recommendations the CDC Should Have Made

Opioid Abuse recommendationsOpioids and the management of pain have been in the spotlight recently, and rightfully so. Many physicians felt like the recent CDC guidelines for doctors in regards to how they prescribe opioids for chronic pain fell short of addressing the real problem, mainly because CDC Director Tom Frieden placed the blame for the opioid addiction crisis on doctors, calling the problem “doctor driven.” Instead of a sweeping generalization saying that doctors are the problem, physicians feel that the new guidelines don’t address other complex challenges, like medical insurance coverage, legislative policies and clinical realities.

Dr. Lynn R. Webster, former president of the American Academy of Pain Medicine, opted to pen an op-ed that included 12 recommendations the CDC should have made instead of their current guidelines. Rooted in stronger evidence than many of the CDC guidelines, Webster believes these 12 recommendations would better address the problem of opioid addiction, and we tend to agree. You can see Dr. Webster’s entire piece by clicking here, or you can see the 12 recommendations below.

The following are 12 additional recommendations with a stronger evidence base than most of the CDC guidelines, and that would be far more likely to reverse the harm from opioids while not creating more suffering for people in pain. In Utah, a multipronged, state-funded program that included provider education (Pain Med 2011;12:S73-S76) with elements from the eight principles mentioned below was followed by a 28% reduction in the number of unintentional, opioid-related drug overdose deaths from 2007 to 2010, as reported by the Utah Department of Health:

1. Apply the “Eight Principles for Safer Opioid Prescribing” endorsed by the AAPM.

2. Use abuse-deterrent formulations when an extended-release opioid is indicated.

3. Remove the cap on the number of opioid-addicted people who can be treated for addiction with medications such as buprenorphine.

4. Allow nurse practitioners to prescribe medication agonist therapy for opioid addiction.

5. Recommend affordable, perhaps free, access to buprenorphine and methadone therapy in line with public policy that recognizes addiction as a disease.

6. Push U.S. and state legislatures to issue mandates to payors demanding a minimum level of benefits for patients in pain to increase coverage for evidence-based alternatives to opioids.

7. Remove methadone as a preferred opioid for pain from state formularies.

8. Ask that payors require prescribers to demonstrate methadone-specific knowledge before being allowed to prescribe methadone for chronic pain.

9. Encourage the U.S. Congress to increase funding to find safer and more-effective alternatives to opioids for the treatment of acute and chronic pain.

10. Recommend legislation for partial prescription filling for Schedule II controlled substances to reduce the quantity of unused prescription drugs.

11. Implement the National Pain Strategy as a top priority.

12. Consider prescribing naloxone with all extended-release opioid prescriptions.

Clinical Trials For Chronic Pain Management

Many patients who have chronic pain are interested in the latest research and want to be a participant in order to get the newest form of treatment. Unfortunately there are not a lot of recent trials that have advanced to the human level for pain medication. Research is also limited in novel approaches to pain. The total funding for pain research related topics is about two percent compared to the total amount of research on all medical areas, even though 30 percent of the population is dealing with pain related issues.

The truth about research is that it is very tedious. For new drugs, it usually starts with trying to find a compound that may have some modifying affect on a part of the pain pathways that we currently understand. Current studies are trying to find new pathways that impact the perception of pain in the nervous system. In reality, much of the research is still at the basic level. We can’t treat pain until we fully understand what is going on in the body when we perceive pain. From the basic science, at some point we hope to be able to find new ways and compounds to manage pain.

Chronic Pain Research Trials

When a new treatment is found, research begins on the computer with complex models to try to predict what is going to happen in living systems. If the basic research is positive, then the study of living systems can begin. Initial studies may be just in cell cultures to see if a compound is toxic. The next level may then be to try a compound out on a lab animal such as a mouse and observe if it’s safe and if it changes the animal’s response to a disease or problem. The initial process of exploration can take years, and most compounds wash out and are found to be ineffective or toxic.

Clinical Trials Pain Chronic MN

If a compound finally clears all the initial hurdles, and may appear to be beneficial for humans, then clinical trials may begin. Human trials have multiple phases. Initially, they are looking at a small group of very clear cases of a problem and whether a drug is safe and is helpful over a control group. The statistics at this stage are that 1 in 30 people have a serious side effect and 1 in 10,000 dies. If the drug is found safe, trials are enlarged, and the safe and effective dose is sought out. The third phase involves an even larger group to further determine safety and make sure it actually does what it is supposed to do. In all these human trials, the subjects are usually highly selected. Subjects must only have the very specific condition and not have other medical problems.

Many patients who have chronic pain have multiple medical issues. Often, chronic pain involves multiple stimuli and causes. Pain is not a simple problem and those who have ongoing pain need to alter their manage strategies, as there is no magical solution. Expecting to join a research study as a chronic pain patient is a very limited option. Very few studies are being performed, and most have very strict criteria to become a subject.

Chronic pain is a very tough medical problem to manage. At this time there are no magic options to control pain. Often pain takes multiple strategies to manage. Constantly looking for that one pill, shot or intervention is often futile. The best solution is usually working with an experienced pain physician and developing an individualized plan that addresses your needs. It usually will not rid you of pain, but it can make life more enjoyable.

Epigenetics Change in Damaged Nerves, Create Pain Memory

Nerve Memory EpigeneticsThink back to the last time your cut your finger or skinned your knee. There was acute pain, but eventually that subsided as your body worked to repair the damage. After a few days, the injury was healed and pain from that incident was nothing but a memory.

That’s how our bodies work most of the time. However, on rare occasions, that injury damages nerves in such a way that pain doesn’t ever subside; it becomes chronic. So why do some injuries fade away, while other people are forced to deal with chronic pain for months or years? Researchers say it’s due to nerve epigenetics.

As researchers from a recent study explain, think of epigenetics as a nerve’s “memory.” Just like traumatizing memories can stick with a person for years, so too can a traumatizing experience for a nerve. And just like a person, although you learn to heal and move on from the incident, certain actions can trigger that memory, and when it happens to a nerve, it can actively send off pain signals.

“We are ultimately trying to reveal why pain can turn into a chronic condition,” said Dr. Franziska Denk, an author of the recent study. “Cells have housekeeping systems….the majority of their content are replaced and renewed every few weeks and months. So why do crucial proteins keep being replaced by malfunctioning versions of themselves?”

For his study, Dr. Denk and his team examined pain signals in mice. They looked at some particular immune cells in the mice and found that when some nerves are damaged, their epigenetics change, and the epigentics remained in an altered state even after the nerve had “healed.” This change in epigenetics caused the nerves to become overly active, firing off pain signals during activity at at seemingly random times.

Dr. Denk’s team wants to conduct further studies to see if they can find a way to coax these damaged nerve cells into letting go or forgetting these traumatic experiences that are causing them to flare up when no pain is actually being experienced. They believe that by doing so, they could help treat millions of people who deal with chronic pain, and they could help stop the current opioid crisis in America.