On Thursday May 4, 2017, a headline article in the Minneapolis StarTribune was on the effect of opioids on chronic pain. The article was written about a study at the Minneapolis VA hospital about not using opioids for patients with chronic pain. The study was done by Dr. Erin Krebs, an Internist who studied patients at the VA. The study involved two main groups of patients who all had back, hip or knee pain. One group received opioids and the other did not during a year of treatment, and both received extensive use of alternative pain management techniques.
The conclusion drawn by Dr. Krebs is that chronic pain patients do not need opioids since the non-opioid group did well with decreased pain intensity. Furthermore, Dr. Krebs, by her limited study, is implying opioids are ineffective to manage chronic pain and should not be used. This is a significant disservice to chronic pain patients and is an especially irritating claim being made by a physician who has practiced in pain management but only in an academic setting and is not even Board Certified in Pain Management.
Chronic Pain and Insurance Coverage
The first take home message for pain patients is that chronic pain is incredibly complex, opioids are only one medication management tool among many treatment options. This study is very limited, and the patient population does not truly reflect the complexity of many pain management practices with people who have multiple medical problems with multiple body locations of pain.
The patients in the study were given comprehensive and unlimited access to a number of treatments from physical therapy, psychological counseling, exercise, acupuncture, interventions and a variety of medications. In the “real” world, it often is extremely difficult to obtain insurance coverage on an ongoing basis for appropriate treatments including for anything that is not generic for medication, exercise programs, or psychological counseling (if a psychologist with interest in pain is even available).
Often the most appropriate management options for a patient are rejected by insurance companies, including a variety of interventional treatments, exercise programs, and non-narcotic medication. Proven interventions like spinal cord stimulation are rejected while the insurance companies have no problems with opioids. Patients who have failed all conventional treatments may benefit from a trial of options such as medical marijuana, and this is definitely excluded by insurance coverage.
The Complexity Of Chronic Pain
Chronic pain is not a single entity. It is a very complex outcome that is associated with multiple medical problems. Pain physicians and most doctors are not treating a single problem like osteoarthritis of the hips or knees – the main group of patients in this study by Dr. Krebs. Simple problems such as those in this study are often easily managed with a combination of conservative strategies and can oftentimes be treated quite well without opioids.
Now, most physicians are trying to avoid the use opioids for these issues when they can. Unfortunately, most physicians do not have enough training and experience in treating many of the problems that cause pain and up until recently, opioids were the easy solution to see a patient in a limited time and get them out of the office with a smile on their face. The solution to the opioid epidemic problem is much more complex then demonizing patients and a medication.
Most physicians are usually trying to do the right thing for their patients. Pain physicians are especially aware of the issues in treating these complex patients. First, coverage for alternative medical treatments for pain must be more easily approved, especially when recommended by a Board Certified specialist. Secondly, pain affects over 30 percent of the adult population and research into pain needs significant funding. Third, addiction to opioids is a separate issue beyond pain management, and needs to be treated in a different sphere, as only a small number of pain patients are addicted versus dependent on their medications. Lastly, there are multiple treatments for pain available, if alternative treatments were easily covered when recommended, less use of problematic drugs would surely occur.
If the media was more interested in telling the life of both legitimate pain patients and their treating pain physicians, a better understanding of how pain affects one’s life may occur. Too many people who have not been there are casting judgement on patients and physicians who are trying to treat a very complex problem. A third of the world population suffers from some sort of chronic pain, far exceeding the number who suffer any other medical problem, but there is hardly any money being spent on research and promoting safe management strategies. Moving forward will require less negative casting of the patients and physicians treating these problems and more investment into positive solutions.
Thomas Cohn, MD
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