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.

Pacing Yourself With Chronic Pain

April 18, 2016 / Thomas Cohn, MD

If one has chronic pain issues, sometimes life requires compromise. Our bodies change as we age. Just like a car, when we are young, not much maintenance needs to be done. As we get older, the parts become worn and it takes more work to keep us running. We can no longer just add fuel and go, we have to do routine maintenance and do special work to keep the body moving. Going full speed ahead may not be the wisest move, and slowing down might be helpful.

3 Aspects of Health and Wellness

In order to keep going, one of the most important aspects of care is to exercise. There are three components to a good program; stretching, strengthening and aerobic conditioning. Like a three legged stool, all of these components are necessary to prevent one from collapsing. When one is young, doing only one aspect may be okay, but if you have chronic pain, without all three it may not work.

Stretching – Muscle tightness and “spasms” often cause pain, so stretching of these areas significantly reduces muscle tightness and pain. Stretching often needs to be done several times a day, once should be fairly extensive, but short 30-60 seconds of isolated stretches may be extremely helpful throughout the day.

Strengthening – Strengthening is essential to maintain the body’s power and ability to perform activity. To be able perform an activity, one needs to have the muscle strength. Performing strengthening of the muscles by using exercises that push the body against gravity, or using machines, weights or bands are simple ways. Simple exercise routines can be found easily in apps for your smart phone or by searching the internet especially for the neck and low back region.

Aerobic Conditioning – The last leg of the stool is aerobic conditioning. Aerobic exercise ranges from walking, to pool exercises, to workouts on treadmills, ellipticals, or bicycles. Conditioning should be for about 30 minutes and be 4-5 times a week.

If one has chronic pain, the intensity and speed that one went at life prior to injury often needs to be decreased. Going all out at any activity often will cause more problems. Despite doing the appropriate exercise, once injured the body is often not perfect thereafter. Expecting to be able to do everything the same as what one did 20 years ago is unrealistic. Spring cleanup or housework that was once done in a single day may now require splitting up the routine over several days and paced out. It may take just a bit longer, but the job will still get done. It often does not matter what route one takes, as long as one gets to the same endpoint.

Once a new car leaves the dealer, it is always deteriorating unless it is never used. Once we reach adulthood, the body is always slowly growing older. It will never be quite the same as it once was in the past. Maintenance is always needed. Pacing ourselves through life will give us longevity. Getting to the endpoint is what is important. Speeding will garnish a ticket; more pain and will not make the journey especially enjoyable.

Alternative Chronic Pain Management Strategies

March 28, 2016 / Thomas Cohn, MD

Chronic pain and prescription opioids are two topics that have been making national headlines over the last few weeks. The CDC announced a new set of recommendations for prescribing opioids and the FDA has required new warnings on opioid medications to ensure labels include more descriptions of the risks, especially for abuse, addiction, and overdosing.

With all the news about the issues with opioids, there has been more interest in alternative strategies toward chronic pain management. In the past, comprehensive chronic pain management programs were a preferred strategy. Over the past ten years, most programs have disappeared due to a lack of insurance coverage. The cornerstone of all these programs is combining conservative use of medications, interventions, and the strong input of physical therapy and behavioral health treatments.

Different Pain Treatment Options

Physical therapy (P.T.) is one of the essential needs of everyone with pain in order to develop a daily exercise program. Further therapy can maximize overall capability and improve the ability to function. The goals of therapy are three-fold. To work on overall strengthening and core muscles, aerobic conditioning, and stretching. Muscle strength allows one to be able to hold up the body and perform activities. Core muscles give the spine the ability to be upright, and most of us do not have good strength in these groups, and with a strong core, spine pain is much better controlled. Pain is often caused by tight muscles, so stretching keeps the muscles at the right length and decreases spasms. All three activities are necessary. It is like a three legged stool; Without doing one of the three, the stool tips over. You need all three bases to be stable.

The next method is a behavioral health intervention, and the goal is to train the brain to help control the interpretation of sensory signals. The brain has incredible power to manage all the signals it receives. Pain sensations are specific sensory signals, and the interpretation of the signals can be consciously modified. Normally the brain would just read these sensory signals as painful. If the brain is receiving many painful sensory signals, a short circuit can occur and the pain can become centrally amplified and intensified. Using techniques taught by psychologists, one can learn to modify the perception of the pain signals and essentially ignore them. Multiple different techniques have been used successfully including progressive relaxation, self-hypnosis, mindfulness, cognitive behavioral therapy and distraction. Again, to be successful with any of these therapies, one has to be interested and willing to put in the time and effort to make the techniques work.

Acute and chronic pain can be very successfully treated and managed with a variety of techniques. Opioid medications in reality are only a very small tool to control these symptoms. Controlling the opioid misuse requires patients to move beyond the want for a simple solution that takes no work. Chronic pain is not well treated with opioids for the long-term. It takes time and effort to control chronic pain, if one does not put in the work, there likely will not be a good solution.