What Pain Patients Want From Their Doctors

November 11, 2019 / Thomas Cohn, MD

Last weekend in the StarTribune there was an editorial on opioids and pain from a neurologist and Chief Medical Officer Regions Hospital. It seemed a bit self-congratulatory about how great he is doing at reducing opioids and how unnecessary they are in most pain situations. It is great to talk about not using opioid medications especially for chronic pain, however if the main job one has is to be a pain medicine specialist, a better understanding of pain and its impact on an individual’s life is needed.

The article brags how many fewer opioid prescriptions have been written by HealthPartners clinics. By the sounds of it, no one was educated on treating pain and way too many scripts were being written. Physician education on management strategies for pain is woeful and minimal time in medical school and residency is spent on training physicians about pain. The best strategy to prevent chronic pain is to aggressively treat acute pain and prevent chronic symptoms from developing. Use a comprehensive strategy early and reduce the impact of pain. Opioids are just one of many tools to treat symptoms, and many better tools are available and should be employed.

Nobody enjoys having pain. Convincing someone that pain is normal is one of the worst strategies to reduce opioid use and abuse. Patients with pain do not want to be told pain is normal, they want their physicians to help determine what is wrong and find good ways to reduce symptoms to a manageable level. Telling a patient pain is normal just informs the patient as a physician you do not care what is wrong and whatever you tell the patient next, they already have the expectation that you have only your own agenda and not their interest first.

Reading the editorial as a pain physician, it was maddening to see the lack of knowledge with regards to how patients feel about their medical problems. Almost everyone knows about the opioid epidemic, but when one has pain, they want compassion, respect and help with understanding their problem finding solutions. They do not want to hear about opioid problems. They want a physician that will help lead them to answers, listen to what they are saying and give them a pathway to improvement. The expectation is that physicians have answers beyond opioids these days, and from a patient’s perspective, bragging about your reduction of the use of these medications is snobbery. Solve the patient’s problem and be empathetic. As a medical big wig, tell your insurance company to pay for proven alternative solutions and give the clinical doctor the ability to use all the tools necessary to help their patients without fighting your bureaucracy.

Minnesota Researching Opioid Alternatives

October 19, 2017October 25, 2017 / Thomas Cohn, MD

Even if you’re not a chronic pain sufferer, you’ve probably heard about the “opioid crisis” here in America. Overdoses and accidental deaths from pain medications have skyrocketed in recent years, and things are only getting more divisive as we try to put an end to overdoses. There are too many competing interests working against one another. For example:

You have a government officials who are supported by money from big pharma.
You have big pharma, who is making a lot of money through the increase in prescription medications.
You have some overworked doctors who jump right to pain pills instead of taking more time to find solutions.
You have some chronic pain patients who take the idea of opioid regulation as a personal offense.

That’s simply too many interests pulling in too many directions, and chronic pain patients are suffering because of it. However, Minnesota has recently taken some tangible steps to look for alternatives to opioids.

Opioid Alternatives

Earlier this month, leading medical minds met in St. Paul to talk about some alternatives to pain management to help combat the opioid epidemic. They discussed a range of possibilities, including such options as:

Electrotherapy
Radio-frequency ablation
Cryogenics
Implantable spinal cord stimulators
Epidural injections
Medical gadgetry
Chemical compisitions
Physical therapy techniques

The goal of the meeting was to help lawmakers understand that they have the ability to influence how research funding can be allocated for some of these alternatives, and that the future of these pain management techniques are worth exploring.

Dr. Clarence Shannon, an anesthesiologist who works in the University of Minnesota Pain Clinic in Minneapolis, spoke about the summit and how it’s important to test out potential treatment options before jumping to opioids.

“It’s a stair-step approach that I like to use: nonsteroidals, anti-epileptics or neuropathic medications. We’ll try radio-frequency ablation if we can. We’ll do nerve blocks. And then we’ll move up to the things like the implantable devices,” Shannon said.

These alternatives aren’t perfect solutions, and while they do have some drawbacks, the downsides are much less threatening to a patient’s health than the negative consequences of opioids. Medical devices may cost more, may be more prone to malfunction and may require battery changes, but those downsides are worth it if they can protect us against opioid abuse and overdose.

A Good Start

The pain management summit was a good start, but we need to also focus on getting everybody on the same page. We need to the government to look at the bottom line in terms of lives saved and not dollars earned. We need to take the burden off doctors so they don’t feel the need to fall back on opioid prescriptions without first exhausting some other options. We need chronic pain patients to realize that searching for alternatives does not mean the government is going to come and take away their prescriptions that they are using responsibly to manage their pain.

We need to work together to find a solution, or we can’t expect anything to change. Hopefully Minnesota can be at the forefront of that change.

Opioid-Related Deaths Increase in Minnesota

January 10, 2017January 25, 2017 / Thomas Cohn, MD

Although we’re still waiting on the numbers from 2016, it’s clear that there is a growing problem with opioid overdoses in Minnesota.

According to new data from the U.S. Centers for Disease Control and Prevention, deaths from opioid overdoses rose in Minnesota in 2015, especially among young adults. The data suggests that 338 people died from opioid overdoses in Minnesota in 2015, up from 319 in 2014. A closer look at the data suggests that the highest number of deaths occurred in individuals in their late 20s and early 30s rather than older individuals for the first time since the 1990s. The problem isn’t contained to the big cities, either.

“It’s hitting rural areas harder than it is cities,” said Rural Aids Action Network program manage Maggie Kazel. “I think that’s a hard concept for a lot of people to grasp because we have a historic setup in our brains of drugs equal big cities. What we see in Duluth is horrible, what they see in Iron Range is pure tragic.

Synthetic Drugs On The Rise

Pain pill abuse has been a problem for a while now, as the number of people killed by opioid overdoses in Minnesota has risen steadily since 1999. The CDC recently awarded Minnesota more than a half million dollars to develop more opioid overdose prevention plans, but it’s not just normal opioids that health officials need to be aware of. According to Dana Farley, the Minnesota Department of Health’s alcohol and drug prevention policy director, synthetic drugs are popping up in Minnesota more frequently. He said synthetic drugs have become more accessible recently, which tend to be more popular in younger crowds. He believes synthetic drugs played a big part in why younger people were dying at such a higher rate in 2015.

Pain Management in Minnesota

We need to develop better opioid management programs here in Minnesota. Doctors and medical professionals can’t keep handing these pills out like candy. Opioids certainly have numerous benefits and they truly help some people, but we need to have better management of how these drugs are administered to ensure they aren’t abused. Too many people are dying, and there’s little sign for optimism based on the trends of the last decade. We need to make preventing opioid abuse a priority in Minnesota.

Obama Weighs In On Opioid Crisis in America

February 23, 2016 / Thomas Cohn, MD

President Barack Obama shot down a proposal on Monday from the nation’s governors designed to curb America’s opioid and heroin crisis. The proposal called for limiting the number of high-powered painkillers a doctor could prescribe at a time, but Obama said the move could block access to drugs that people truly need.

“If we go to doctors right now and say ‘Don’t overprescribe’ without providing some mechanisms for people in these communities to deal with the pain that they have or the issues that they have, then we’re not going to solve the problem, because the pain is real, the mental illness is real,” Obama said. “In some cases, addiction is already there.”

The recommendation had received bipartisan support at the National Governors Association’s winter meeting, but President Obama rejected the sweeping proposal. The president thanked the governors for crossing party allegiances to come to a solution, but he didn’t think it adequately addressed the full scope of the problem.

“This is an area where I can get agreement from Bernie Sanders and Mitch McConnell. That doesn’t happen that often,” Obama said.

Opioids in America

According to the Centers for Disease Control and Prevention, heroin and prescription painkillers play a roll in the deaths of 78 Americans every day. Certain prescription opioids are seen as gateway drugs to heroin, which is cheaper and often much easier to obtain.

Vermont Govermor Peter Shumlin criticized Obama for rejecting the proposal, saying, “You can’t convince me that we’ve got 250 million Americans in chronic pain.”

The fact of the matter is that opioids are likely over-prescribed in this country, and while some doctors certainly hand them out too easily, for some patients, it is truly the only option that keeps their pain at bay. For others, surgery or costly therapy sessions are out of the question, so they rely on those painkillers to manage their pain. Dr. Steven Stack, president of the American Medical Association, praised Obama for shutting down the blanket rule which would have undoubtedly hurt a large portion of actual chronic pain sufferers.

“The complexity of the problem makes it difficult to create a successful one-size-fits-all approach,” Stack said.

Stack is right. There is no perfect one-size-fits-all approach to chronic pain care, just like there is no magic pill to solve one’s pain. In the end, we need comprehensive exams to understand to underlying cause of pain, and we need to work with patients to understand their treatment options and the potential implications of each. It’s much harder than simply prescribing a painkiller, and it also takes work on the patient’s end to work to get better and not just rely on their pain pills, but this duel-responsibility approach is what it’s going to take to start reversing the opioid crisis.

More Than 90% of Patients Who Overdose Prescribed More Painkillers

January 5, 2016 / Thomas Cohn, MD

A new report suggests that more than 90 percent of patients who suffer a nonfatal overdose on prescription opioid painkillers are prescribed more pills following the overdose.

In certain situations, opioids can and do help prevent some of the pain caused by chronic conditions, but they are prescribed far too often by doctors who don’t take the time to get to the underlying cause of pain. The findings confirm this unfortunate trend.

The research, published in the Annals of Internal Medicine, suggest that not enough is being done to help treat pain patients, and the patients are the ones suffering. According to the findings, 91 percent of pain patients who suffered an opioid-related nonfatal overdose were later prescribed more opioids, and opioid overdose survivors who continued to take medications were twice as likely to have another overdose within two years.

It’s saddening but not surprising that these findings have been published, especially when you consider that the Centers for Disease Control and Prevention recently published an article saying opioid induced overdoses have reached epidemic levels. According to the CDC overdose deaths from prescription opioids and heorin have increased 200 percent since 2000.

Opioid Epidemic

Lead researcher Mark LaRochelle of the Boston Medical Center hopes the findings will be a wake up call for doctors who prescribe a lot of opioids.

“The intent of this study is not to point fingers but rather use the results to motivate physicians, policy makers and researchers to improve how we identify and treat patients at risk of opioid-related harms before they occur.”

For their study, researchers examined insurance claim data of more than 50 million people who filed a claim between 1999 and 2010. After narrowing their list down to 3,000 people who had suffered an opioid-induced nonfatal overdose on their prescription, researchers checked to see what care the patients received after their near death experience. Shockingly, nearly all of the survivors continued to receive opioid painkiller prescriptions, and, of the patients who remained on painkillers, 70 percent of them were prescribed medications from the same doctor who prescribed them the medications they eventually overdosed on. According to researchers, those doctors may have continued prescribing opioids after the overdose because they may not have known about the overdose, or they still felt the benefits outweighed the potential downfalls. They also believe some doctors may be ill-equipped to be making opioid judgments after an overdose.

The CDC issued guidelines suggesting that physicians should cut back on opioid prescriptions after a nonfatal overdose. Instead, they should pursue physical therapy or non-opioid painkillers.

Related source: ZME Science