Physician Education is Key to Chronic Pain Management

Two themes to which I find myself frequently returning:

1. Primary care doctors are overwhelmed by and ill-equipped to deal with chronic non-cancer pain patients and related long-term opioid therapy; and
2. Mandatory physician education would make a significant difference in the fight against opioid misuse and abuse. 

A paper just published from the University of Missouri puts some data around both of these themes and offers an encouraging path forward on physician training (online link not yet available).

Hariharan Regunath, MD, and some colleagues in the Department of Medicine at the University of Missouri conducted a survey asking 45 internal medicine residents about outpatient chronic non-cancer pain management with opioids.  Some unsettling, but not altogether surprising, results:

• 77.8% reported lack of training in this area
• 86.7% reported lack of consistent documentation from other providers
• 62.2% had at least 1 patient about whom they had concerns for misuse or addiction
• On the bright side, 86.7% believed that focused education could make a difference

So the researchers decided to try some focused education!  After reviewing the results of the initial survey, Dr. Regunath and his team put together a series of educational modules specifically targeting the areas of identified knowledge deficits among the surveyed residents.  

The results were fantastic:

(on a scale of agree to neutral to disagree, % that "agreed" is reported in the table below)

The authors note that despite these compelling results (albeit among a small sample), progress is slow.  "Even at this time, medical education in chronic pain management is still not a mandatory Accrediting Council of Graduate Medical Education (ACGME) component..."  This attitude among the medical education establishment - what's done cannot be undone... or revised, or updated, or improved, even in the midst of a public health crisis - is utterly ridiculous.  

I guess if we can't get mandatory education in place for currently practicing doctors, we might at least start with medical schools and residency programs?  The doctors of the future deserve it.  And so do their patients.   

Michael 

On Twitter @PRIUM1

A Prescription for Preventing Overdose Deaths

I've been openly critical of the American Medical Association's approach to the opioid epidemic. I've labeled it "necessary, but insufficient" - meaning that the initial recommendation of the AMA's Opioid Abuse Task Force was to encourage physicians to register and use their state's prescription drug monitoring program (PDMP).

Politically safe.  Glaringly obvious.

In response to that blog post, several physicians reached out to me to express their frustration with the AMA.  One of PRIUM's physician consultants pointed out that AMA membership now represents a mere 15% of practicing physicians in the US.  I checked that stat and she's right.  AMA membership has been steadily declining since the 1950s, when nearly 75% of physicians belonged to the group. I'm beginning to understand why (though I'll admit the AMA's support for the Affordable Care Act and the rise of specialty physician associations has certainly contributed).

I did award points for the AMA's willingness to join the discussion and offer solutions.  I expressed hope that this was just the start and that we would see further, more aggressive measures among the future recommendations that the task force promised it would be making.

This week, the AMA Task Force has offered the next step: "With the United States in the midst of an opioid misuse, overdose, and death epidemic [emphasis added], the AMA Task Force to Reduce Opioid Abuse strongly encourages widespread access to naloxone as well as broad Good Samaritan protections to those who aid someone experiencing an overdose."

Politically safe.  Glaringly obvious.

We should all be advocating for increased access to naloxone, though I've focused my advocacy on providing the overdose antidote to first responders and care givers in high risk populations.  The concept of co-prescribing and physician standing orders (every script for an opioid comes with a script for naloxone) troubles me.  The AMA statement encourages doctors to ask the following questions when considering co-prescribing naloxone:

• Is my patient on a high opioid dose?
• Is my patient also on a benzodiazepine?  
• Does my patient have a history of substance use disorder? 
• Is there an underlying mental health condition?  
• Does the patient have a co-morbid respiratory disease?
• Might my patient be in a position to help someone who is at risk of overdose?

With the exception of that last question, this should represent the list of questions doctors ask themselves to determine whether they should continue to prescribe opioids at all (vs. considering whether to prescribe another drug to counteract the potentially disastrous side effects of the current medication regimen that is so obviously dangerous, the risk of overdose appears imminent).  

This latest set of necessary, helpful, but totally insufficient recommendations from the AMA helped me to recognize what I think is the fundamental issue with their approach: These recommendations are focused on how to deal with risks after the drugs are prescribed and dispensed.

So here's my challenge to the AMA: What can we do before the drugs are dispensed?  

(Here's a hint: mandatory education would be a big help). 

Michael 

On Twitter @PRIUM1

Oxycontin for Kids

The FDA has approved Oxycontin for children. 

Before I editorialize, a few important facts:

• Specifically, the approval is for children ages 11-16 that require daily, round-the-clock, long-term pain relief for which no other alternative exists. 
• FDA actually requested that Purdue study this; this isn’t Purdue trying to extend its patent through dubious means.
• The only other FDA-approved long acting analgesic available to kids who have, say, incurable cancer, is Duragesic (or fentanyl).
• I have an 11 year old.  

That last fact turns out to be pretty important.  My first reaction to this news was outrage.  I’ve never pulled punches with my criticism of the FDA and I was fired up to skewer them again for being utterly tone deaf to the greatest public health crisis of our time.  But I first saw this news while sitting at the breakfast table with my three kids, the oldest of whom is 11.  After finishing a few articles on the FDA move, reading emails from several of you who struck tones of anger and confusion in varying degrees, and processing my initial shock, I looked up at my kids and wondered…

I am incredibly blessed to have healthy kids.  But if my kid had incurable cancer and he was suffering from intractable pain, would I want him to have Oxycontin available to him?  Yep.  I sure would. 

On the other hand, I thought… What if he blew out an ACL playing soccer when he’s 15?  Would I want him to have Oxycontin for post-op recovery, even if he was in great pain?  No.  Absolutely not. 

If we trust that Oxycontin will be used only in those extenuating and heart breaking circumstances for which this approval is intended, then I could support that. 

But what if the message coming through armies of pharma reps employed by Purdue is that Oxycontin is now approved for “round the clock pain management, when no other alternative exists… even for teens suffering from post-op pain related to major sports-related surgeries…”?  Do we have proper controls in place to ensure that doesn’t happen?   One need only read this crushing article in Sports Illustrated to understand that we’re already overprescribing opioids to teens, particularly athletes.  How do we make sure this doesn’t make it worse? 

Pediatric oncologists are thrilled. 

Public health advocates are gravely concerned.    

I'm not comfortable with ambivalence, but in the case I have to admit: Both are right.  

Michael
On Twitter @PRIUM1

1 in 4 Opioid Scripts Ends Up "Long Term"

The Mayo Clinic wanted to assess the risk factors associated with opioid use.  They started by asking, "How many opioid prescriptions end up leading to long term use?"

Turns out, 1 in 4.  

Specifically, the researchers found that 21% of first-time prescriptions led to use for 3-4 months and 6% of first-time scripts led to use longer than 4 months.

Those time intervals are silly, aren't they?  From our perspective in work comp, we're seeing material numbers of injured workers progress (or, perhaps, regress) to 3-4 years of opioid use after the first script.  Personally, I'd like to see a study that tests use patterns over much longer duration intervals.  I also suspect that the work comp population exhibits a higher "long term use conversion rate" than a randomly selected patient population.  System design tends to reward certain stakeholders for disability duration.

The research is also intriguing because it examined the specific risk factors that lead to long term use. Nicotine use and prior substance abuse issues were the top risk factors.  While this isn't necessarily surprising, we see scant evidence that these risk factors are being taken into account at the time of the first opioid script.  The best predictive models in our industry are certainly telling us that these patients are at higher risk, but if the prescribing doctors aren't taking this information seriously and using it to inform an alternative, non-opioid treatment plan... what's the use?

Faster, more focused interventions with prescribers will be key to preventing long term opioid use.

Michael
On Twitter @PRIUM1

The Research is Catching Up to our Experience

I see a theme among recent posts: pointing to new research that confirms things we already knew because we see them in claims every day.  This is good news.  The science is catching up to our practical experiences with opioids, addiction, and chronic pain.

The latest confirmation comes from the Cleveland Clinic.  In an article published in the Journal of Pain late last year, researchers assessed the likelihood of opioid abuse based on past history of non-opioid substance abuse.  For those of us close to complex chronic pain cases, we know that a history of, say, alcohol abuse, is correlated with opioid abuse.  But until now, we didn't have compelling data from peer reviewed literature to back our intuition.  Granted, cross-substance abuse is a well known research area... but this study focused specifically on opioids among patients with chronic, non-cancer pain.  

Among other important conclusions, here's what I thought was most important: In a pain rehab program, participants with a history of a nonopioid substance use disorder had 28 times the odds of having an addiction to prescribed medications.   

What does this mean for you?  

1. Every injured worker, every claim, every doctor... must have an opioid risk assessment performed prior to any potentially addictive prescriptions are written.  
2. Doctors must be educated on how to interpret the opioid risk assessment and use it to tailor treatment to the individual needs (and risks) of the injured worker.  

Failure to complete these two steps will invite tragedy.  

Michael
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