Opioids – Why Patients and Physicians Are Frustrated

May 25, 2016May 25, 2016 / Thomas Cohn, MD

Every 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.

Here are the 12 Recommendations the CDC Should Have Made

May 19, 2016 / Thomas Cohn, MD

Opioids 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.

Extended-Release Oxycodone Approved By FDA

April 29, 2016May 10, 2016 / Thomas Cohn, MD

The US Food and Drug Administration has approved extended-release oxycodone (Xtampza) as another option for controlling chronic pain.

The FDA gave the drug tentative approval at the end of 2015, but the agency gave extended-release oxycodone the official green light earlier this week. The pill, known as Xtampza ER, comes in the form of capsules and is intended to be taken twice-daily for patients who deal with constant or severe chronic pain.

The extended-release formula is designed in such a way that abusers are unable to get a quick high off the drug. The drug maintains the extended-release property which helps stop people from crushing, chewing or manipulating the pill to get a concentrated effect. Dr. Jeffery Judin, Director of Pain Management and Palliative Care at Englewood Hospital and Medical Center, said the drug’s design should help prevent abuse.

“Abuse-deterrent opioids are critical component to fighting the widespread national epidemic of prescription opioid abuse,” said Dr. Gudin.

The medication comes in 10 mg, 15 mg, 20 mg, 30 mg and 40 mg strength, and is expected to be launched for patient use in the United states by the middle of 2016. Side effects of the drug includes gastrointestinal distress, nausea, headache, sleepiness and stomach pain.

This drug may eventually be a viable option for someone who deals with mild to moderate chronic pain throughout the day. The extended-release formula is great because it helps prevent opioid abuse, and it can provide long lasting relief. That said, when any new drug hits the market, there needs to be careful observation to understand how it is best managed and used to control symptoms. Extended-release pills also tend to be more expensive than regular drugs and sometimes aren’t covered by insurance. We’ll keep our eye on this drug and the reports surrounding it in the coming months.

Chronic Pain – Is It Anyone’s Fault?

April 25, 2016May 10, 2016 / Thomas Cohn, MD

The epidemic of opioid abuse has been flooding the news media, and the CDC has recently published new guidelines for prescribing opioids. Advocates associated with addiction wrote the guidelines without input by those providing primary care or pain management. This has led to a very unbalanced set of recommendations. The press has also been publishing countless articles blaming medical doctors for causing the addiction crisis by overprescribing pain medication.

Unfortunately, managing pain is quite complex. In medical school, doctors are taught basic concepts of how opioids work and how long they last in the body. Beyond understanding how opioids are used to treat pain, very little else is taught in medical school or specialty training about treatment of pain. Addiction education also gets very little time in the overall training of doctors. Furthermore, it is drilled into physician’s head that one must relieve pain and suffering. Then, most medical providers naturally tend to prescribe the easiest solution, opioids.

The Blame Game

One of the largest medical problems affecting all patients is chronic pain, afflicting over a third of the population worldwide. The problem of pain far exceeds medical problems like cancer, heart disease, and diabetes. In the United States, barely 2 percent of the research dollars in medicine go to the study of pain, and there is no coordinated center in the National Institute of Health or other government agency to sponsor further investigations.

The problem of providing pain management for those suffering from chronic pain and those with expertise in this field is clear. There are millions of people, a third of the population who suffer from chronic pain. The field of pain management is very small with only a few thousand experienced providers. The tools to provide pain management are somewhat limited. One of the most effective tools for pain has been the main tool for several hundred years – opioids. It is often not the best drug for pain in many patients and situations. However there is no money available for many better treatments and research with regards to new and better tools is limited.

Insurance companies also severely limit the options. Drugs that are not addictive are often denied since the use is outside the original approval guideline set by the FDA. Other times the insurance companies will only approve drugs that are not approved FDA treatments because there is similar generic drug. Non-drug treatments like additional or long-term physical therapy, massage, or comprehensive pain management programs are also denied due to upfront costs. Thus physicians are forced into prescribing pain medications that may be addictive since better treatments are not covered by insurance.

The physician and the chronic pain patient did not cause the opioid epidemic. It is a complex problem. To solve the issues associated with pain, there needs to be better education of doctors as well as patients about management strategies. Money needs to be spent on more than treatment of addicts, but on solving the complex facets surrounding pain. Allowing pain experts to prescribe appropriate treatments including medications and comprehensive programs is a start. Research on the mechanisms of pain and how these might better be managed whether with new medications and strategies also needs to be performed. The guidelines likely will only educate people that there is an opioid problem. The solutions are much more complex than the new guidelines proposed by the CDC and written by addiction specialists who run a multi-million dollar string of treatment centers.

Chronic Pain Across America

April 15, 2016 / Thomas Cohn, MD

Chronic pain is defined as any pain that lingers for more than 12 weeks, and you may be surprised to learn that it affects more than 100 million Americans every year. As part of our effort to help spread awareness about chronic pain and how these complicated conditions are treated, we wanted to share this handy infographic we found on the web.

If you enjoy the infographic, check out some of these related articles that focus on the diagnosis and treatment of chronic pain in America!