Friday, February 28, 2014

Research: Weaning Works Wonders

I hear skepticism all the time about the difficulty of weaning patients off of high doses of opioids in the outpatient environment.  Frankly, I hear skepticism about being able to wean them at all, but especially in the outpatient environment.  And when the alternative involves inpatient detox (and its associated price tag), the claim handler often feels stuck. 

New research suggests that not only is outpatient weaning possible, even in light of extremely high doses of opioids, but that the weaning has a positive clinical effect on the patient in terms of pain scores, depression levels, and activities of daily living.

In an admittedly small sample (16 patients), doctors weaned patients on an average of 945 mg morphine equivalent dosage - or MED (with a range of 300 mg MED to 2,960 MED) down to an average of 275 mg MED (with a range of 0-750 mg MED) over an average of 17.4 weeks. 

The patients' average pain scores (measured via the Brief Pain Inventory) dropped from 7.2 to 4.9 and their average depression score (measured via the Patient Health Questionnaire-9) dropped from 13.5 to 9.5.  The results were statistically significant. 

The next step is clearly to replicate the research on a broader set of patients.  That said, this research confirms what we're seeing at PRIUM among the legacy claim work comp population on high doses of opioids. 

We can wean these patients.  We can do it on an outpatient basis.  They will get better as a result.  They will cost less as a result. 

On Twitter @PRIUM1

Friday, February 14, 2014

Doctors No Longer Allowed to Take Patients' Blood Pressure

Ok, that's not true.  But an analogous and equally dangerous law suit is unfolding in Indiana.

In response to our nation’s prescription opioid epidemic, several states have enacted laws to help stem the tide of opioid misuse and abuse.  Notably, Indiana has passed a law requiring that patients prescribed opioids must submit to urine drug testing at the beginning of treatment and at least once a year thereafter.  This type of testing is best practice, guidelines driven, and in the best interests of patient safety.

The American Civil Liberties Union (ACLU) disagrees.  They’ve sued the state on behalf of a chronic pain patient who has been prescribed opioids for 18 years and doesn’t want to submit to mandatory urine drug testing.  The ACLU claims such testing is a violation of this man’s 4th amendment rights, which bar illegal searches and seizures.

This is like a patient with diabetes suing over a doctor’s assessment of his hemoglobin a1c levels.  Or a patient with high blood pressure suing over a nurse actually putting a blood pressure cuff on the patient to assess his current BP.  Or a patient on warfarin… or a statin… or any other drug that requires constant clinical monitoring to ensure patient safety and efficacy of the medication therapy. 

Urine drug testing isn’t a “gotcha!”  Healthcare providers and patients both benefit from the information collected from such testing.  Important clinical decisions about dosage, efficacy, and side effects are influenced by urine drug testing results.  Though rare, genetic abnormalities involving the metabolism of opioid medications can be discovered through urine drug testing. 

These drugs are some of the most potent and dangerous medications ever devised.  And they are miracle drugs for those who legitimately need them to function on a daily basis or to provide comfort in the waning days of life.  But to ensure safe, proper, and efficacious use of these medications, testing such as that which Indiana mandates is more than just good public policy – its good medicine.

On Twitter @PRIUM1

Thursday, February 13, 2014

When Judges Get in the Way

Louisiana is a troubled state.

With five Circuit Courts of Appeal, a state law may be interpreted in five different ways.  A new law may be found unconstitutional in one circuit, constitutional in another, and it may be that no constitutional question in raised in the others.  As a result, when the legislature makes a change to the law, it has to anticipate not just one unintended interpretation, but, potentially, five distinct interpretations existing simultaneously.  It also has to anticipate the possibility that none of those interpretations will allow the new law to do what it was intended to do.

Again, Louisiana is a troubled state. 

This is especially true when it comes to workers’ compensation.  The Louisiana State Legislature has made several attempts to promote responsible treatment of injured workers, but it seems that each attempt has been undermined by at least one of the five Circuit Courts of Appeal.

The legislature authorized independent medical examinations (IMEs), but the Fourth Circuit ruled that an injured employee can’t be compelled to attend an IME unless the employer already has medical evidence in its possession showing that an IME is necessary.

The legislature authorized utilization review, but the Third Circuit ruled that utilization review by itself was an insufficient basis for denying treatment.

The legislature authorized the Workers’ Compensation Administration to promulgate treatment guidelines in order to ensure that all injured workers were treated according to a single standard of care based on current medical evidence, but as of January 22nd, all but one of the appellate courts have effectively ruled that Louisiana has two standards of care for workers’ compensation claims.

On January 22nd, the Second Circuit Court of Appeals found that the medical treatment guidelines authorized by § 23:1203.1 did not apply to those cases because the date of injury in each case predated the effective date of the guidelines: July 13, 2011.

Following this ruling, a doctor treating an employee who was injured on July 13, 2011 will have to comply with an enumerated standard of care based on current medical research .  A doctor treating an employee who was injured on July 12, 2011 will have no such responsibility.

Louisiana law says that there will be new treatment guidelines with new effective dates every two years.  As Judge Caraway’s dissent points out, the majority’s interpretation would create different sets of law for each two year period.

Decisions like these are upsetting -- not just because they fail to address the problem of irresponsible treatment… not just because they create a new problem by creating (at least) two very different standards of care… but because they bind the hands of the only people who can fix that problem.

On Twitter @PRIUM1

Wednesday, February 12, 2014

Addiction: Not About "Good Guys" vs. "Bad Guys"

I recently read an appeal by Dr. Kelly Erola, CMO for Hospice Savannah.  She wrote about halting the attack on pain pills and argued on behalf of legitimate uses for opioids – cancer patients undergoing chemotherapy, hospice patients, and patients with serious injuries and acute pain.

She makes an important point.  Opioids are an effective and powerful tool that bring immeasurable relief to individuals suffering severe pain.  Let’s be sure that those individuals always have a means of getting the care and the drugs that they need.

What struck me was the contrast she drew between “law-breaking addicts” and “law-abiding patients.”  In my view, this is a component of our societal struggle with opioids, but misses the most fundamental and dangerous aspect of the opioid crisis: the group that lies in the middle – “law-abiding addicts”. 

Yes, pill mills are a problem.  So is drug diversion.  So is the unintended consequence of illicit drug use.  But the group most in danger is, in fact, the law-abiding patient whose physician is prescribing high doses of opioids to treat conditions such as non-specific low back pain.  Millions of patients are losing out on the benefits of what contemporary medical evidence tells us is most appropriate for the treatment of chronic pain: get up, move, exercise, lose weight, sleep better.  Instead, physicians continue to write prescriptions for powerful pain relievers, leaving us with millions of “law-abiding addicts”. 

Any clinician will rightfully point out that I’m taking certain liberties with the word “addict” here.  Addiction is a real disease characterized by aberrant, drug-seeking behaviors – the very behaviors that often lead to illegal activity on the part of the patient.  The point I’m trying to make is that many of these “addicts” didn’t start out as criminals.  And there are millions of patients not technically addicted, but nonetheless entirely dependent on prescription opioids on a daily basis.  Dr. Erola highlights a single battle in the opioid crisis, but this is where we’re losing the war.

If the public policy distinction was as black and white as Dr. Erola suggests, the solutions would be simpler.  In reality, the problem of prescription drug misuse and abuse goes well beyond a simple matter of “good guys vs. bad guys”.  Any public health or regulatory discussion around opioids has to acknowledge that there are lots of “good guys” (i.e., law-abiding patients) being hurt, too. 

On Twitter @PRIUM1