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.

Independent Medical Examinations After An Injury

January 29, 2018 / Thomas Cohn, MD

One of my least favorite tasks is seeing what an Independent Medical Exam (IME) has said about any of my patients. IMEs are evaluations performed on a patient usually at the request of an insurance company or sometimes an attorney. Theoretically, these are to be used to determine the true nature of the medical problems and to provide recommendations for ongoing management of a patient. Usually they are performed in cases where there may be legal issues involved; mostly commonly the insurer is either workman’s compensation or auto insurer. These exams are performed by physicians who are often not actively in practice, and may not even have expertise in the area of treatment. Therefore the quality and purpose of such an exam is often questionable.

The Inherent Problems With Some IMEs

In my distant past, I also performed independent medical exams, most commonly for insurance carriers in workman’s compensation cases. The most common reason why insurers sent patients to my office is that they wanted to know what was really wrong with their clients and what may be the anticipated cost for future treatment. A good evaluation by a Physical Medicine and pain expert can at least tell them what is actually wrong with their client, and what are likely going to be necessary future treatments.

Instead of denying any injury ever occurred, several of the insurers took the proactive step to determine what was going to be the best way forward. Since they knew that I was going to tell the truth about the patient’s medical condition, it was valuable and a positive experience for both the patient and the insurance company. The last one I performed was a year ago and I had to ask if they knew the results may not be in the insurance company’s favor and if they would be okay with whatever I determined. Surprisingly, they really just wanted to know what was wrong with their client.

Most independent medical examinations I see are ordered by an insurance carrier and they only will hire physicians that they know will find any way deny that a medical problem exists. Often the physician will minimize an injury, and then report it as not feasible that the patient’s complaint can be present. The history taken is usually very short, and a physical exam is limited. The physician then develops “alternative facts” and delivers the “fake news” back to the insurer. Honesty and an understanding of pain, as well as most conditions that cause pain, is absent. The overall purpose is to minimize liability by the insurance carrier in a future legal setting. These exams are used to limit any ongoing medical care for a patient. The frustrating factor for the patient is that if these were done in a true independent manor and actually were done by professionals with real skill and understanding of the medical problems, then they could actually be useful.

Preparing For Your IME

The take home message for a patient who needs to undergo such an exam is that they need to be knowledgeable about the process. The patient should consider recording the exam for their own record, whether it is having a witness, taking notes or actually filming or recording the event such that one can counter incorrect information in any report. It is important for the patient to be fully cooperative and not combative and really participate in any exam such that any abnormalities will be evident. Lastly, insist that the report be made available to you or your legal representative so inaccuracies can be addressed later.

Rarely are independent medical examinations done to develop a full understanding by all parties involved in settling medical-legal issues. For a patient, the results of these exams should be taken with skepticism at best. For lawyers and insurance companies, honest and good exams would likely be more helpful. To develop future plans for a patient, currently the best source of information is usually the treating physicians. If the insurance company really wants to know what is wrong with a patient with a musculoskeletal problem, recruit the use of an experienced, board certified Physical Medicine physician. A good expert who can explain a range of management options is the needed expert to help settle questions in patient management.

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.

Kratom and Chronic Pain

January 10, 2018 / Thomas Cohn, MD

kratom Every 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.