Penny-A-Pill Plan Proposed To Prevent Opioid Abuse

February 22, 2018 / Thomas Cohn, MD

Minnesota Governor Mark Dayton has proposed a “penny-a-pill” program in which drug companies would have to pay the state an extra penny for every pill prescribed in the state. The money raised from this tax would go towards an opioid stewardship program that provides opioid prevention, treatment and recovery services.

Gov. Dayton said the program may be able to generate $20 million a year.

“You can call it whatever you want,” Dayton said. “It means that they’re going to pay for the product they’re producing, which is causing this epidemic.”

According to data, there were 395 opioid overdose deaths in Minnesota in 2016. That number represents an 18 percent increase from the previous year, and 194 of the 395 deaths were linked to prescription opioids. The CDC also notes that there are 47 opioid scripts written for every 100 Minnesotans.

One Of Many Changes

The penny-a-pill program is just one of a number of changes aimed at reducing the number of opioid overdoses and deaths here in Minnesota. Two months ago, the state announced new guidelines that affect how area physicians write prescriptions for painkillers. The new guidelines suggest that physicians should:

Prescribe the lowest effective dose and duration of opioids when used for acute pain.
Monitor the patients closely, including prescribing opioids in multiples of seven days.
Avoid initiating chronic opioid therapy, make it so long term prescriptions would include face-to-face visits with the provider at least every three months.

Additionally, Minnesota wants to renew the focus on educating physicians, patients and their families on the potential dangers of opioids, as well as how to spot the signs of a problem.

“One opioid prescription can start the downward spiral in the right person,” said Dr. Rahul Koranne, Chief Medical Officer for the Minnesota Hospital Association.

Minnesota is actually one of the better states in the US when it comes to regulating prescription opiods. The state prescribes the fifth fewest opioids in the nation, which speaks volumes considering there are 47 scripts written per 100 Minnesotans.

Do you think the penny-a-pill program is a good idea? Leave your thoughts in the comments section below.

FDA Declares Kratom An Opioid

February 13, 2018 / Thomas Cohn, MD

We’ve blogged about Kratom in the past, but now the FDA is chiming in on the subject. According to the FDA, Kratom is more than a plant, it is an opioid.

“As the scientific data and adverse event reports have clearly revealed, compounds in kratom make it so it isn’t just a plant — it’s an opioid,” said FDA commissioner Scott Gottlieb. “And it’s an opioid that’s associated with novel risks.”

Kratom, which has been credited with giving users feelings of euphoria, strength and pain relief, has now been linked with 44 deaths. Aside from its obvious dangers, the FDA decided to classify the plant as an opioid because the drug taps into some of the same brain receptors as opioids.

The Dangers of Kratom

Like a number of drugs in their infancy, the dangers of kratom stem from the fact that we haven’t had much time to scientifically study the substance. Despite never gaining approval from the FDA, kratom was advertised as a concentration booster and workout enhancer in largely unregulated supplements. Because of its properties, it also made its way into the pain management community as a potential option for individuals with chronic pain. And ironically, it’s also been touted as a treatment option for opioid addiction.

“Patients addicted to opioids are using kratom without dependable instructions for use and more importantly, without consultation with a licensed health care provider about the product’s dangers, potential side effects or interactions with other drugs,” Gottlieb said in a previous statement.

Now that we’ve had more time to study the substance, researchers are realizing just how dangerous unregulated kratom use can be. After studying the chemical structures of the 25 most prevalent compounds in kratom, researchers discovered that they all shared similarities with opioids like derivatives of morphine. Moreover, two of the five most prevalent compounds in kratom latch onto the brain’s opioid receptors, just like other opioid painkillers do.

“The new data provides even stronger evidence of kratom compounds’ opioid properties,” Gottlieb said.

Some states have already taken steps to ban the substance, and it wouldn’t be surprising if Minnesota followed suit in short order. Kratom is already banned in Alabama, Arkansas, Indiana, Tennessee and Wisconsin.

At the end of the day, we have to remember that there is no miracle pill that can cure us of our pain or treat our opioid addiction. Trust that doctors have your best interests at heart, and that clinically tested and proven methods are best.

The Unforeseen Opioid Issue

February 5, 2018 / Thomas Cohn, MD

This week, another issue of opioid use to control pain came to light in the news. In a suburb of Minneapolis, a patient was in a nursing home type facility. Along with whatever issues brought them to the facility, apparently they had pain and were receiving opioid medications. At the nighttime dose, a staff nurse, probably in a hurry, gave a huge dose of the medication instead of the proper dose without noticing the mistake. By morning the patient was dead from an overdose. All opioids can cause breathing problems especially in those who are sick, and too much medication can easily be deadly.

The overdose of anyone by a person administering medications is unfortunate and should never happen. Two lessons are clearly evident. First, always double check to make sure you are taking the right medication and dose, and second, be aware that these medications are dangerous. When prescribing opioids, medical personnel should always be careful on how much medication is being prescribed and try to avoid giving excessive dosages.

If there are no alternatives, then be careful. Evaluate for medications that may interact with the opioids, such as sleep medications that may suppress breathing or anxiety medications. Check the person’s history for other medical conditions that affect breathing, like lung disease and sleep apnea, since opioids may disrupts breathing patterns. Make sure the person is mentally capable of taking the medication correctly, and that they are not suicidal, depressed, or dealing with dementia, because this too can also lead to an opioid overdose.

Narcan’s Role In Preventing Overdose Deaths

Besides the above and a bit of common sense, preventing opioid overdose deaths is important. Many providers are adding a prescription of Narcan nasal spray when writing scrips for opioid medications. This is a medication that can block the effects of opioids and reverse its medical effects completely in the body. Narcan can block the respiratory or breathing problems from an opioid, but it will also reverse any pain relief. It is easy to deliver, it is shot as spray up the nose and will quickly reverse only the opioid-induced problems. However, for the new synthetic opioids like fentanyl or carfentanyl that are being abused with heroin, multiple doses may be needed in treatment.

Now, anyone receiving any significant amount of opioid for pain should receive Narcan nasal spray. The person who is normally taking the opioid may not need the Narcan unless they accidentally take to much medication. Otherwise, if someone else in the home of the opioid user takes the medication on purpose or by accident, the Narcan can be used to reverse the opioid and prevent death. As always noted, opioids are not ideal pain medications and can be easily deadly. Having and using Narcan in cases of emergency can prevent an untimely death.

Balancing Best Practices and Patient Satisfaction

January 24, 2018 / Thomas Cohn, MD

You 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.

Making Pain Patients and Doctors Feel Like Outlaws

January 15, 2018 / Thomas Cohn, MD

An 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.