Balancing Best Practices and Patient Satisfaction

patient satisfactionYou would think that in all cases, giving the patient the optimal treatment plan will result in a satisfied patient. Surprisingly, this is not always the case. In an ideal world, a doctor would have a healthy and satisfied patient, but if they have to sacrifice one for the other, your doctor is going to put your health over your satisfaction.

Balancing the best treatment plan and patient satisfaction is especially tough in the world of chronic pain care. For example, in a recent study of nearly 20,000 people with musculoskeletal pain conditions, individuals who were prescribed opioids to manage their pain were much more satisfied with their care. Individuals who used opioids moderately were 55 percent more likely than non-users to report high levels of care satisfaction, and heavy opioid use was associated with a 43 percent higher likelihood of reporting high satisfaction. The more doctors prescribe, the better the chance patients are satisfied with their care.

The problem with prescribing opioids because it will satisfy patients is that overdose and abuse can set in at any time. Taking opioids for chronic pain is a primary risk factor for dying of an opioid overdose, and an overdose leaves many unsatisfied people in its wake.

Prioritizing Health

As we’ve said on the blog many times in the past and will continue to preach on here, we’re not anti-opioid. Pain medications can play a pivotal role in a pain management plan when closely monitored and administered. Instead, we’re anti doctors who prioritize gaining favor or satisfying patients by prescribing pills when it is not in the patient’s best interest or it is not coupled with active treatment modalities, like exercise, physical therapy or diet changes.

The study that analyzed patient satisfaction also pointed out a major flaw in the healthcare system – doctors are often compensated based on patient satisfaction, either directly on the paycheck, or indirectly in terms of online reviews and word of mouth. So we have a system that rewards doctors for doing what the patient wants, instead of what’s best for the patient. Providing the best care and satisfying the patient don’t always go hand-in-hand in pain management, and when doctors see more benefits in appeasing the patient than doing what’s best for them, it’s the patient who suffers.

Doctors are a lot like personal trainers at the gym. You aren’t going to grow muscles by wearing an ab band and sitting on your couch, you have to pick up some weights and put in the work. The same goes for treating your chronic pain condition. There is no magic pill that will allow you to heal without putting in the work on your end. You might not like your doctor at the end of the day, but if you find a good doctor, you’ll know that they truly do have your best interests in mind. Down the road, you’ll thank them.

Decoy Molecule Could Stymie Chronic Pain

rnaResearchers at the University of Texas at Dallas believe they have created a new weapon in the war against chronic pain. According to researchers, they say they’ve created an RNA-mimicking molecule that can block a series of pain sensations that normally occur after an injury. By studying how this molecule interacts with pain sensations, researchers believe they may be able to develop a new class of drugs that can prevent pain at the outset without increasing a person’s risk of addiction.

“Our results indicate that local treatment with the decoy can prevent pain and inflammation brought about by a tissue injury,” said study lead author Dr. Zachary Campbell.

He believes the findings are very important because chronic pain-related conditions are “the primary reason Americans are on disability.”

“Poorly treated pain causes enormous human suffering,” said Dr. Campbell, “as well as a tremendous burden on medical care systems and our society.”

Cutting In To Opioid Abuse

Opioid addiction and overdoses have increased in recent years as more people turn to pills to help manage their pain. In the right hands with the right dosage, opioids can play an integral role in a pain management plan. However, opioids can be a slippery slope to addiction if they are abused, which is why researchers are looking to develop new medications that are abuse deterrent.

Our current opioids have a major disadvantage in that they interact with areas of our brain that deal with reward and emotion. This can lead to a craving or addiction to the reward stimulus that the drugs provide, but by studying the artificial RNA-molecule, we may be able to develop drugs that stop pain in other areas of the body without crossing the brain-blood barrier.

This artificial molecule works in nociceptors, which are special cells at the injury site that help send pain signals to the brain. After the injury, RNA molecules begin the process of facilitating proteins that signal pain. By mimicking RNA, the decoy molecule can interrupt this process that makes these proteins, and reduce our body’s behavioral response to pain.

“When you have an injury, certain molecules are made rapidly. With this Achilles’ heel in mind, we set out to sabotage the normal series of events that produce pain at the site of an injury,” said. Dr. Campbell. “In essence, we eliminate the potential for a pathological pain state to emerge.”

This is certainly an interesting development, and I hope it opens up new ways to combat chronic pain. We’ll keep an eye out for more information about this protein in the coming years, as it may have big implications for how pain is managed.

Making Pain Patients and Doctors Feel Like Outlaws

painkiller abuse doctorAn opinion piece by Dr. Thomas Cohn

I spent Friday evening with my staff trying to get authorization for medications for one of my patients. The process started on Wednesday when we changed the opioid dosing to a more logical plan based on the needs of the patient. That is when the problem started with the insurance company. We obtained the first authorization for the long-acting medication, then the change for the short-acting medication was refused since the insurance company decided it was too high a dose for a month. We were given a peer review and scheduled a time for the review, but the insurance company physician did not call. We then were finally told on Friday at 3:00 p.m. that the doctor would talk to us and we called immediately.

This was a total sham, the doctor read the insurance company guidelines and said he had no ability to change what was written. Since I have done many reviews as both the reviewer and the one asking for review, the person reviewing can tell the insurance company the rationale for any decision for a patient if medically indicated. It did not seem like anyone at the insurance company cared about the patient.

Villianizing the Patient

For starters, a few patients have very significant medical conditions that may be appropriately treated with opioids. For cancer patients, there is no question that it is within reason to treat with these medications. Some patients also have severe medical conditions that are causing progressive deterioration of the body and likely will lead to death eventually, and opioids also are reasonable. Lastly, some patients have failed every other treatment or surgery and were left with such significant body dysfunction that opioids are the only thing that helps manage pain. These patients are extremely compliant, not abusing their medications, and are being treated by reputable providers, not pill mill doctors. Unfortunately, this patient fell into the class of having a nasty progressively deteriorating neurological condition that has been causing significant pain as well as difficulty with daily activities.

Trying to obtain understanding for the patient who needs medications is supposed to be relatively straightforward. There are guidelines on prescribing to reduce using medications inappropriately, especially in acute settings for starting an opioid regimen. For patients who have legitimate uses for these medications, they are supposed to be able to obtain them if the physician feels it is indicated. Again, this patient appears to have a very significant neurological disorder affecting the whole body, and it is causing significant pain that other treatments will not stop and other medications do not help.

As a pain physician, I was being asked by her other doctors to manage the pain medications. Being board certified in pain, one would think recommendations for medications would have good reasoning as well as being up-to-date with concerns of abuse. If another board certified pain physician saw the recommendations made, I am sure they would agree on the treatment. So when a peer review occurs and the physician says he can do nothing, it is clearly not a well-trained physician and they should not be reviewing such a complex case. The insurance company should fire such doctors from their review panels. Furthermore, it can put a patient in jeopardy since needed medications are not obtainable.

Insurance Problems

The insurance company also had a major fail in patient management. The doors close at 5:00 p.m. on Friday. All the phones start rolling over to automated voice call systems. There is no emergency contact person available to obtain authorizations. There is no contact person for any information so the patient can obtain the necessary treatment. Friday and the weekend comes, and you are out of luck.

The most infuriating aspect of the process is no one seemed to care at the insurance company, the pharmacy benefits company or the patient’s pharmacy. I was totally insulted by the Walgreen’s pharmacist who implied that they could not prescribe because physicians like me were causing the opioid abuse problem and patients like the one receiving the medications were obviously abusers. Statements like that are divisive and show clear ignorance and bias. Legitimate pain patients should not be made victims and neither should their physicians.

The opioid crisis is a problem related to addiction and only minimally related to pain management. In pain practices run by board certified physicians that are providing full service management strategies, opioid abuse is likely less than 5 percent of those patients using medications. When the need is legitimate, pain physicians should be given the ability to make the right recommendations and not need to waste time on approvals versus providing treatment. There are very few specialists in pain care, and providing appropriate medication management by these physicians should be encouraged.

Beyond just prescribing, the insurance companies need to step up and pay for the complex solutions like injections, behavioral health interventions, physical therapy, health clubs, dieticians and other integrative approaches to pain management. The patient and the physician trying to develop appropriate treatment plans should not be stymied but encouraged. The chronic pain patient and board certified pain physicians are not the cause of the opioid crisis. The opioid crisis is really a crisis that started from the lack of treatments for pain. Find the solutions for pain and the addiction crisis will start to crumble. Until we understand pain management, we may continue to have a opioid abuse crisis.

Kratom and Chronic Pain

kratomEvery once in a while the herbal supplement kratom makes the news. Last November the FDA decided to classify kratom as a schedule 1 drug like heroin or marijuana, but after some opportune lobbying, the decision was put on hold. It is a substance that has been around for hundreds of years, mainly in Southeast Asia, and what it is and what it does is still poorly understood. Recently, some have claimed that it has the potential to be helpful in managing pain and opioid withdrawal.

The Truth About Kratom

Kratom is an herbal substance derived from the leaves of a Southeast Asian tree of the Mitragyna species, which is an evergreen. The leaves are either chewed or used to make an extract. Traditionally, in Southeast Asian cultures it was used for wound healing, coughs, intestinal infections, and to relieve stress and enhance moods, especially for those in boring repetitive labors.

The effects of kratom are dose dependent. At a low dose it acts like a stimulant, and at moderate to high doses it can act like an opioid. Even at low doses it can cause problems like:

  • anxiety
  • agitation
  • nausea
  • loss of appetite

At high doses, especially on a frequent basis, serious side affects can occur similar to problems with opioids including hypertension, weight loss, constipation, and even seizures and psychosis. Sudden stopping of high dose kratom can mimic withdrawal from opioids. The full pharmacology has been studied only in animals.

Kratom was first reported as an opium substitute in Malaysia and Thailand in the early 1800’s. From the traditional use, it has now become an herbal substitute for opioids for either managing pain or for withdrawals. In most of the world its sale and use are either controlled or prohibited. In the United States, the DEA was going to list it as a Schedule 1 drug like heroin, but due to legislative pressure they decided to leave it alone. In November of 2017, the FDA noted concern about sales and marketing since it can have serious side effects. Further, there have been no quality scientific studies on the effectiveness of kratom for either pain or prevention of withdrawal.

Substances like kratom should be considered very carefully before use. Like any herbal substance, this is not a pure drug and its potency can vary. The difference between an herbal substance and a medication like ibuprofen or aspirin is the dose and chemistry is fairly well understood with predictable effects. A dose of a herbal substance like kratom may be variable and the effect can be as toxic as regular use of opioids.

There may be beneficial properties to kratom, and further actual scientific studies would be useful. Perhaps a pure extract someday may lead to a very helpful compound to treat pain. However, until further understanding is determined, kratom use may be fraught with the same issues of any other opioid-type compound.

The Gender Disparity of the Opioid Crisis

chronic pain pills womenA recent opinion piece in the Star Tribune shined a light on the problem different genders face in the opioid crisis, particularly the challenges faced by women.

One of the main talking points is that deaths from opioid overdoses have increased much faster for women than for men. Female deaths from opioid overdoses have increased 400 percent in recent years compared to 265 percent for men. Both of these numbers are very problematic, but it helps to show that the opioid crisis is affecting each gender differently.

When opioids affect women, it can oftentimes have a bigger trickle down affect than when it affects men. As the article states, in most American families the woman is the primary caregiver, and the woman’s well-being is often closely tied to the health and future of the children. Opioid abuse by the primary caregiver can often lead to problems down the road for the children, and it increases their likelihood of having their own battles with substance abuse. When opioids negatively affect women, it rarely impacts just one person.

Fixing The Problem

The article went on to suggest some ways to reduce opioid disparity and the larger problem of gender-based health disparities in the United States. Some of the proposed solutions include:

  • Addiction risk education for doctors and patients
  • More education has led to fewer opioid prescriptions and in some places, a downturn in overdose deaths
  • Better emergency room treatment
  • Education campaigns to change dosage standards for women
  • Increased doctor education in states where women disproportionately suffer from conditions like obesity, high blood pressure, diabetes, chronic pain and heart problems
  • Stop cutting insurance coverage for certain programs like Medicaid and Medicare

It’s clear that there’s no one-size-fits-all answer for fixing the opioid crisis and gender-based healthcare disparities throughout the country, but the first step is to help spread awareness that a problem exists. Then we need to put a plan of action in place and stop making the bottom line a higher priority than the health of the patient in our office.

Opioids certainly have a place to help patients when properly assigned and administered, but far too often they are being blindly prescribed and without safety measures in place if abuse begins. The Star Tribune article is a step in the right direction by calling attention to the problem, but now we need doctors, patients and our legislatures to follow through. For the sake of women and families across the country, I hope we can work towards a solution.