Chronic Pain Patients Struggling To Find Primary Care Services

July 15, 2019 / Thomas Cohn, MD

A new study published in JAMA Network Open found that chronic pain sufferers have a harder time finding primary health care because they have an active prescription for opioids.

According to the study, 40 percent of the nearly 200 primary care clinics contacted as part of study said they would not accept a new patient who takes Percocet daily for chronic pain as a result of a past injury, no matter what type of health insurance they had. An additional 17 percent of clinics said they would want more information about the patient before deciding if they would take them on, with two-thirds of this subset saying the patient would be required to come into a preliminary appointment before a decision could be made. Despite these findings, all of the clinics said they were currently accepting new patients.

The findings suggest patients with a history of chronic pain could face health care access problems.

“Anecdotally, we were hearing about patients with chronic pain becoming ‘pain refugees’, being abruptly tapered from their opioids or having their current physician stop refilling their prescription, leaving them to search for pain relief elsewhere,” said study lead researcher Pooja Lagisetty, M.D., M.Sc. “However, there have been no studies to quantify the extent of the problem. These findings are concerning because it demonstrates just how difficult it may be for a patient with chronic pain searching for a primary care physician.”

Slippery Slope

Dr. Lagisetty said for patients with chronic pain conditions, getting access to primary care goes beyond just checkups and preventative care. Having a regular physician could allow them to receive other pain-relieving treatments, and in some cases, work with the new provider to gradually and safely taper off their use of opioids. Primary care providers can also help recognize the signs of opioid use disorders or addictions, so not accepting patients simply because they are trying to manage their pain only works to further the crisis.

“We hope to use this information to identify a way for us to fix the policies to have more of a patient-centered approach to pain management,” said Dr. Lagisetty. “Everyone deserves equitable access to health care, irrespective of their medical conditions or what medications they may be taking.”

It’s easy to accept the healthy young adult at your clinic, and it can be harder to take on the patient managing multiple health conditions, but both should be guaranteed access to primary care providers. We need more doctors who are willing to take on the harder patient.

Opioids, Medical Marijuana and Chronic Pain

April 10, 2019 / Thomas Cohn, MD

When it comes to managing chronic pain, we’re always looking for new and better ways to help patients control their discomfort. If you’re a regular follower of our blog, you probably know that we’ve written a number of blogs on opioids and medical marijuana, but a recent study decided to take a look at what happened when these two treatment plans were used simultaneously. You might be surprised at the findings.

According to research presented at the 2019 American Pain Society Scientific Meeting, individuals with chronic pain who used both prescription opioids and recreational marijuana showed higher levels of mental health and substance abuse problems than those who use opioids alone. Now, the study makes a big distinction noting that patients were using marijuana recreationally and not medicinally, but it still shines a light on how problems can occur when people try to supplement their opioids with other substances.

Study Results

Those weren’t the only findings that were of concern according to researchers. The team said that anxiety and depression scores were also significantly higher for patients who used both opioids and recreational marijuana, as were measurements of opioid dependence severity and alcohol and cocaine involvement. Researchers also noted that there was no difference in pain severity or pain disability between the group of individuals just using opioids and those using opioids and recreational marijuana.

“The things psychologists would be most worried about were worse, but the thing patients were using the cannabis to hopefully help with — namely pain — was no different,” said Andrew Rogers, University of Houston, who worked on the study. “Co-use of substances generally leads to worse outcomes. As you pour on more substances to regulate anxiety and depression, symptoms can go up.”

Abhiram Bhashyam, MD, MPP, of Massachusetts General Hospital in Boston, who was not involved with the study, said the findings provide even more evidence that patients shouldn’t assume that recreational marijuana will help with the effects of their chronic pain if they are already on opioids.

“This study provides further evidence that cannabis may not be an effective substitute or alternative to opioids for pain management,” said Dr. Bhashyam. “Studies like these are important for clinicians as patients increasingly ask about opioid-cannabis co-use for managing their pain. We lack robust evidence to provide appropriate guidance due to a paucity of research on this topic at present.”

Both opioids and medical marijuana can be helpful if you’re dealing with chronic pain, but it’s important to realize that there’s a significant difference between regulated medical marijuana and recreational marijuana, so don’t assume that what you pick up on the street will be beneficial in combination with opioids for your pain. As this study suggests, it doesn’t appear to help and it can certainly make some problems worse. If you’re considering medical marijuana or another treatment plan for your pain, consult with a physical medicine specialist first to ensure you’re making the right choice for your individualized condition.

Could New Opioid Laws Lead To Higher Costs For Patients?

March 14, 2019 / Thomas Cohn, MD

As we explained in a blog post earlier this month, the Food and Drug Administration is going to begin conducting more studies on opioids and forcing drug manufacturers to examine if their products are effective at managing specific chronic pain conditions. While these changes are aimed at helping combat the opioid epidemic, some patients believe the costs for these studies will be passed onto them.

There’s also concerns about cost and access to medications at the local level. Here in Minnesota there has been a bipartisan push to raise registration fees on drug companies to fund treatments and implement more fail-safe addiction policies. A vote on these measures is expected int he coming weeks, but some patients believe these changes forced at the business level will be felt hardest at the consumer level.

Who Funds These Changes?

Cara Schulz, who advocates for patient rights, believes the higher costs and restricted access to medications will affect those who need the drugs the most. Schulz currently takes pain medications to manage discomfort following her stage 4 colon cancer diagnosis.

“I want us to work on ways we can manage addiction, I want people to not be addicted, period. But we can’t say we are going to fix addiction by hurting people who are not addicts and who are just patients trying to be treated by their doctors,” said Schulz, who is in remission.

Instead, Schulz believes the real focus should be on fentanyl and other illicit synthetic substances, not prescription medications. At a minimum, Schulz hopes that patients who meet a certain threshold can earn an exemption so their access to drugs they truly need doesn’t become restricted.

“The method that they’re taking to address this problem puts pain patients and cancer patients squarely in the cross hairs,” she said.

This is something to keep an eye on as we move forward with ways to combat the opioid crisis. With more regulations being forced on big businesses, we have to ensure these costs aren’t just passed down the line to patients. Medication costs are expensive enough in the US, and we won’t be putting the patient first if their medications cost an arm and a leg.

FDA Reexamining Opioids For Chronic Pain

February 26, 2019 / Thomas Cohn, MD

The Food and Drug Administration has announced that it will require drug companies to conduct studies to determine if prescription opioids are effective in treating chronic pain.

A number of studies have already suggested that pain controlling opioids are ineffective beyond 12 weeks, and many industry professionals say that continued opioid use after this period can increase a person’s likelihood of developing a dependence or addiction. The FDA wants to supervise the new studies to determine if certain changes, like the following, need to be made:

Changing the labeling on certain opioids
Imposing special rules for prescribing, dispensing and taking certain opioids
Prohibiting use of certain opioids in some cases

“We are going to impose a mandate on existing products . . . to answer the question that people have been posing for years: whether you have declining efficacy, and whether that declining efficacy can lead to addiction,” said FDA Commissioner Scott Gottlieb.

Some Don’t Agree

While it may seem like a good move that the FDA is appearing to take a step in the right direction of opioid abuse, others say the new measures are nothing more than a stall tactic for big pharma. Andrew Kolodny, director of Physicians for Responsible Opioid Prescribing, said the FDA ordered a similar measure in 2013 and that they already have all the research they need to make changes that could help protect the public.

“Here we go again,” Kolodny said in an interview. “That’s exactly what the FDA said to us in 2013. . . . Five years later, we don’t have the studies and another FDA commissioner says, ‘We’re going to do the studies.’ ”

However, Gottlieb argued that the research would be aimed at immediate, extended-released and long-acting opioid tablets that are given for pain care outside the healthcare facility. The studies would also cover current medications on the market to examine if new applications of the pain reliever could be more effective. The FDA will also be conducting a second study that is out to determine if opioids can actually cause users to become more sensitive to pain.

A similar study was carried out back in 2013, but Gottlieb said those studies were difficult to carry out because the FDA could only ensure post-marketing studies on safety, not effectiveness. They now have the authority to demand effectiveness research as part of an act passed back in October.

The opioid crisis killed 47,600 people in 2017, but there’s hope that the new research can lead to effective changes. There’s still plenty of work to be done, but with more control over effectiveness research, there’s hope on the horizon.

Could Wearables Replace Opioids For Pain Management?

October 5, 2018 / Thomas Cohn, MD

Chronic pain affects roughly 100 million Americans, and the pain management market is estimated to be about $635 billion a year. With so many people to treat and money to be made by finding new, safer treatment options, a number of different technology companies are jumping into the world of pain management.

One area that is of particular interest to these companies is wearables and how they can be used to combat and treat chronic pain. A recent study involving more than 1,600 people with distal and proximal chronic pain focused on the Quell wearable device. The wearable allowed patients to track their pain in real time, including changes in pain intensity and pain interference with sleep, activity and mood on an 11-point scale. Patients tracked these changes over the course of two months, and researchers analyzed the findings at the conclusion of the study.

But tracking wasn’t the only feature available with the wearable. The unit actually provided high-frequency transcutaneous electric nerve stimulation. Many patients found that when they wore the device and it was emitting signals, that their pain levels decreased.

“[We found] statistically and clinically significant decreases in pain interference with activity and mood” and “a clinically significant decrease in pain intensity and less pain interference with sleep,” researchers wrote.

Wearables and the Future of Chronic Pain Management

The quell device was only helpful for a select number of people dealing with certain types of chronic pain, but the technology behind the device is exciting. It’s like a hybrid Fitbit and TENS unit, and as the technology continues to progress, we may soon see wearables that can work to drown out pain signals in all different areas of the body.

We understand the science, but because pain is such an individualized issue, there’s no one-size-fits-all wearable for chronic pain. Opioids do a better job of controlling a wider type of pain, but they come with their own potential drawbacks, including potential addiction and dependence. Wearables do not present the problem of dependence, but the tricky part is getting them to impact the specific nerve pathway that is causing pain.

We need to keep investing money in these alternative treatment options and in pain management as a whole. It seems like we’re nearing a breakthrough, not just with wearables, but as a whole. Pain is a huge industry affecting tens of millions of people, so it’s going to draw attention and investments. The first company to develop a wearable or another opioid alternative that can reliably control certain types of widespread pain will set the bar and enjoy the spoils that come with it. This will lead to more investments, better technology, and hopefully, better non-opioid patient care options for chronic pain. We’re excited to see what the future holds.