Holistic Approach To Eliminating Opioids

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Each year, more than 300 patients with chronic pain take part in a three-week program at the Pain Rehabilitation Center at Mayo Clinic in Rochester, Minnesota. 

Their complaints range widely, from specific problems such as intractable lower-back pain to systemic issues such as fibromyalgia. By the time patients enroll, many have tried just about everything to get their chronic pain under control. Half are taking opioids.

In this 40-year-old program, that’s a deal breaker. Participants must agree to taper off pain medications during their time at Mayo.

More than 80 percent of the patients who enroll stay for the entire program, said Wesley Gilliam, the center’s clinical director, and many previous opioid users who finish the treatment report six months later that they have been able to stay off opioids. Just as important, he added, they have learned strategies to deal with their pain.

But such a program is not for everyone. Insurers might disagree that the intensive, interdisciplinary approach is medically necessary for some patients or simply not cover the program’s billing codes, he said. Mayo’s insurance team is sometimes an advocator on a patient’s behalf if they are a good candidate for treatment, however,  success is not assured.

Mayo’s program is not the only one to address the emotional, social and psychological aspects of pain, and other programs also focus on reducing patients’ reliance on addictive medications to manage their pain. But as our nation weathers an opioid epidemic, there are too few programs like these around the country to address the need, Gilliam says.

Gilliam, is a clinical psychologist with a specialty in behavioral pain management and talks about the program.

Q: How do pain medications work? By blunting the pain?

They blunt some of the pain. Opioids are very effective for acute problems, but they were never designed to be used chronically. They are not effective in the long term.

Opioids are central nervous system depressants. They soothe people who are in distress. Many people are not demonstrating improved functioning when they take opioids; it’s calming their nerves and it’s chemical coping.

Q: In treating pain, does it matter what may be the cause or it’s severity?

Pain is pain. The fundamental approach to self-managing it does not change based on the cause or severity of the pain. 

Q: How is someone chosen for a program such as yours?

Virtually all of our patients have tried and exhausted primary and secondary treatment options for pain.

[In] primary care, a patient has a complaint and a treatment plan is developed. It generally involves encouraging the patient to be active, to stretch, maybe the doctor initiates a non-opioid medication like a non-steroidal anti-inflammatory or an antidepressant.

If the patient continues to complain of chronic pain, the primary care provider will step up to level two and refer someone to a neurologist or maybe a pain psychologist or pain anesthesiologist.

If patients do not respond, they start to think about step three, which is a pain program like Mayo.

Q: How does the Mayo program work?

People come to us every weekday from 8 a.m. to 4 p.m. for three weeks.

We do not take a medical approach. It’s a biopsychosocial approach, [which] acknowledges not only the biological aspect of pain, but also recognizes that psychological and social variables contribute to how people experience pain.

That is not to say that pain is imagined, but rather how people experience pain is influenced by mood, anxiety and how that person’s environment responds to the person’s symptoms.

A more medical approach tends to focus on targeting and eliminating symptoms at the expense of the recognition of individual differences.

Q: What does that mean for the patient who’s in pain?

People need to accept that they have pain and focus on their quality of life. Some approaches reinforce in patients that the only way you can function is if you reduce your pain, as measured on a pain scale from zero to 10.

We focus on how to get a person back into their life by focusing on function instead of eliminating symptoms and pain. When I refer to functioning, I mean getting back into important areas of their life such as work, social activities and recreation. If a person is waiting for pain to go away, they are never going to get back into their life. When that happens, people get despondent, they get depressed.

Q: So how do you help people manage pain?

When a person is in chronic pain and it’s poorly managed, the nervous system can get out of whack. Their body behaves as if it’s under stress all the time, even when it’s not. Their muscles may be tense and their heart and breathing rates elevated, among other things.

With meditation and relaxation exercises, we are trying to teach people to learn how to relax their bodies and hopefully kick in a relaxation response.

If I have low-back pain, for example, during periods of stress, muscular tension is going to exacerbate the pain in my back. We focus on helping people to disengage from their symptoms.

By learning to relax in response to stress, muscular tension can be diminished and the experience of pain eased. This does not require a medication or a procedure, just insight and implementation of a relaxation skill.

Relaxation/meditation training is one component of a much broader treatment package. All aspects of our treatment — cognitive techniques for managing mood, anxiety and anger, physical therapy, occupational therapy — are all designed to settle the nervous system.

Q: Does insurance typically cover the program? 

Insurance companies may want to see patients complete more conservative treatment approaches before approving an interdisciplinary pain rehabilitation program like ours.

There are patients whose policies do not cover our billing codes. If we deem a patient as a good candidate, we will write letters saying they should be accepted.

There are a very select few who have paid out-of-pocket for our program. This is a significant minority, however. The program can cost up to $40,000 for someone with other complicated medical problems in addition to chronic pain.

There are studies that show these programs do save money over the long term in health care costs and reduced health care utilization.

If we are going to manage this chronic pain problem, we have to look at it for what it is: multifaceted. You cannot just treat the symptom, you have to treat the whole person.

Many Doctors Say Opioids Are Not The Answer

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Man and family memberPeople who have experienced pain, especially gnawing, chronic pain, know that it affects their happiness, outlook and the ability to function. 

In the past couple of years, the treatment of chronic pain has undergone an earthshaking transformation as opioid addiction continues to claim — and ruin — lives.

Many primary care doctors no longer liberally prescribe opioid painkillers such as oxycodone, fentanyl and hydrocodone for back pain, migraines and other chronic conditions. Instead, they are increasingly turning to alternative medications and non-drug options such as acupuncture and physical therapy.

“Most primary care doctors are afraid to do pain management because of the opioid backlash,” says Michael McClelland, a health care attorney in Rocklin, Calif., and former chief of enforcement for the state Department of Managed Health Care. “Either they don’t prescribe anything, and the patient remains in pain, or they turn them over to pain management specialists so someone else is writing that prescription.”

As a result, McClelland says, “people in genuine pain are going to find it more difficult to get medicine they may well need.”

Anita A., who asked that her full name not be used to protect her family’s privacy, says that happened to her father, Fred, when they moved from Maryland to the Sacramento area in November 2016.

Her father, 78, suffers from back pain that two surgeries did not alleviate. For more than a decade, he took opioid medications under the supervision of pain specialists in Maryland. He has tried “every other medicine,” in addition to acupuncture, nerve block injections and more, but the opioids worked best to control his pain, she says.

“He doesn’t take more than he needs and he’s not seeking to take more,” Anita says.

But in California, two pain specialists declined to see her father, saying his case was too complex. Finally, a primary care physician referred him to a different pain specialist, who saw him in January 2017, three months after starting the quest.

“It’s frustrating,” Anita says. “You get the sense that the medical society is treating everyone as a potential addict.”

A year ago, the Centers for Disease Control and Prevention issued new guidelines for primary care doctors prescribing painkillers for chronic pain, which did not apply to patients receiving active cancer, palliative or end-of-life care. The guidelines recommend doctors to first prescribe non-opioid medications, such as ibuprofen and acetaminophen, and urge non-drug treatments such as physical therapy.

When opioids are used for acute pain, such as that caused by injury, the guidelines suggest doctors prescribe the lowest-effective dose for the shortest-possible time — often three days.

In California, a statewide database known as CURES records opioid prescriptions. Last year, Govenor Jerry Brown signed a bill that requires prescribers to check the database and see if their patients have received these drugs from other doctors.

Opioids are highly addictive, and over time patients need higher dosages to achieve the same pain relief because their bodies develop a tolerance to the drugs.

 

“We don’t have any evidence to support the use of daily opioid therapy beyond about three months for chronic, non-cancer pain,” says Dr. Ramana Naidu, an anesthesiologist and pain management specialist at the University of California, San Francisco. “All of these individuals who have been on opioids for many years  have been doing so without any support from medical literature and science.”

Long-term use also comes with a plethora of possible and unpleasant side effects: constipation, confusion, low testosterone, difficulty urinating, weakened bones and more. And in a counterintuitive twist, opioids can make patients more sensitive to pain.

In some specific circumstances and at a low dosage, opioids can be used over the long term for chronic conditions when “patients have improved quality of life and function, no side effects and no concerns about misuse, abuse or addiction,” Naidu says. But in those cases, he requires his patients to take a “vacation” from opioids every two to four months.

As the Centers for Disease Control and Prevention guidelines recommend, pain specialists are now looking to non-opioid medications plus a variety of non-drug treatments to help patients with chronic pain. These include acupuncture, massage, yoga and visits to pain psychologists.

Penney Cowan, founder and CEO of the American Chronic Pain Association, based in Rocklin, worries that some doctors are not treating their patients as individuals with unique needs. She’s hearing from members whose primary care physicians are simply refusing to refill their opioid prescriptions. 

Liz Helms, president and CEO of the California Chronic Care Coalition, believes some people in chronic pain should be able to get opioids as long as their use is carefully managed by physicians. “That doctor-patient relationship is key to ensuring that someone stays out of pain so they can function,” Helms says. 

Clearly, there is disagreement between some doctors and patients. If a patient finds themselves in the middle and in pain, here are a few suggestions:

First, a patient will need to accept that drugs, especially opioids, are not going to be the cornerstone of pain management and be open to other options, whether it’s alternative medications or other therapies.

“It’s harder work and not the quick fix of opioids, but in the long run, they are better for good health,” says Dr. C.Y. Angie Chen, an assistant clinical professor at Stanford Medical School who specializes in addiction medicine.

Second, it pays to be honest with the doctor and ask questions. If the doctor suggests no more opioids, ask the doctor to explain how he/she plans to decrease the medication.

And if a patient has not yet contacted a pain management specialist, request a referral. Cowan suggests talking with the pharmacist as well. “Pharmacists are the most accessible of all,” she says. “They can provide useful information about medications.”

Take a look at the “Pain Management Tools” section of the American Chronic Pain Association’s website for more resources, or call 800-533-3231. Ask about the support groups the organization sponsors.

Call the California Chronic Care Coalition at 916-444-1985 or visit its My Patient Rights website at www.mypatientrights.org.

Finally, Dr. Chrystina Jeter, clinical instructor of pain medicine at UCLA Health, wants people to know that she and other pain physicians are ready to help, even if a patient does not agree with their decisions to change a treatment plan.

“If I tell a patient they have to taper the opioids or that I can no longer prescribe  opioids, it’s not because I want to cause discomfort or that I do not care,” she says. “My primary job is to keep a patient safe, and I have a lot of evidence now to suggest that the prescribing habits of 10 years ago were not in patients’ best interest in the long run.”