Holistic Approach To Eliminating Opioids

Leave a comment

Couple exercising

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.

Popularizing Prescription Drugs

Leave a comment

rx-bottle-and-cashLaura Ries was moved to action when she saw a TV commercial portraying a woman happily sharing time with her grandchildren after taking Lyrica, a prescription medication, for diabetic nerve pain of which her elderly mother suffers.

“The ad showed someone who was enjoying life again,” said Ries, president of a marketing strategy firm in Atlanta, who then researched the drug and spoke with her mother’s doctor. “This was very related to what my mom was experiencing.”

Her reaction was precisely the aim of ‘direct-to-consumer’ advertising: getting patients or their family members to remember a drug’s name and ask the doctor for a prescription.

Spending on such commercials has grown 62 percent since 2012, even as ad spending for most other product types was flat.

“Pharmaceutical advertising has grown more in the past four years than any other leading ad category,” said Jon Swallen, chief research officer at Kantar Media, a consulting firm that tracks multimedia advertising. It exceeded $6 billion last year, with television picking up the lion’s share, according to Kantar data. Major network evening news and daytime drama programs are heavy with drug ads.

But the increase of drug advertisements has generated new controversy, in part because the ads inevitably promote high-priced drugs, some of which doctors say have limited practical utility for the average patient-viewer. For example, 60 capsules of Lyrica costs about $400 [the drug Ries asked about for her mother].

Critics, including the American Medical Association who called a ban in 2015, say ‘direct-to-consumer’ advertising inflates demand for new, more expensive drugs and encourages patients to ask their doctors for often marginal — and sometimes inappropriate — drugs that are stimulating high health care costs.

Such prohibition is unlikely. Previous efforts to push such an outcome have stalled, generally on free-speech arguments by the powerful drug lobby who declare that such ads provide valuable information to patients about treatment options.

Spending Zooms

One thing is certain: ‘direct-to-consumer’ advertising is big. And, as nearly everyone who watches TV knows, it’s getting bigger.

Some programs — the nightly news and sitcoms aimed at older Americans — get most of their advertising from drug companies. A Kantar analysis shows 72 percent of commercial breaks on the “CBS Evening News” have at least one pharmaceutical advertisement. Commonly, the ads target a range of conditions that generally affect this demographic. Sixty-two percent of commercial breaks during “General Hospital” include a drug ad.

“A lot of these ads target the caregivers and the children of older people,” said consultant Tom Lom, a former managing partner of Saatchi & Saatchi Consumer Healthcare, which has created ads for pharmaceutical giants.

Drug companies were on track to spend an estimated $6.4 billion on ‘direct-to-consumer’ advertising in the U.S. last year, up 5 percent from 2015, according to Kantar. In 2012, spending for pharmaceutical TV ads was the 12th-largest category. By last year, drug ads were sixth.

While substantial, the spending was less than the amount spent by automakers, retail and restaurants. Networks — ABC, CBS, NBC — along with cable channels like CNN — draw a lot of the pharmaceutical advertising.

According to Swallen, the effect of the ban on networks would be a daunting, 8 percent loss of total ad revenue, and its impact would be most evident for programming popular with viewers older than 60 ­— for instance, evening news shows. Similarly, cable networks such as the Hallmark Channel, which draw viewers from this demographic, would feel the pinch because they work on lower budgets.

Why Some Drugs Are Advertised

For years, the ‘direct-to-consumer’ industry was mostly focused on drugs that relieved chronic, typically non-fatal afflictions like heartburn (Nexium), allergies (Claritin) and high cholesterol (Lipitor).

More recently, Lom said, advertising has focused on more serious illnesses affecting seniors, such as Alzheimer’s disease. Ads for drugs that target constipation caused by other drugs — opioids — hit the scene last year, reflecting the large numbers of people taking painkillers.

In 2016, the top three ads based on total spending were Lyrica, $313 million; Humira, $303 million; and Eliquis, $186 million, according to Kantar Media.

The reasons why some drugs are advertised more than others vary, with drug companies evaluating which products are most likely to bring them the most revenue.

Drugmakers do not care “whether it’s a rare, expensive drug or a popular cheap drug,” said Amanda Starc, associate professor of strategy at Northwestern’s Kellogg School of Management. “They’re looking at the marginal return on advertising. A small number of customers spending a lot or a big number spending a little.”

How Advertising Plays To Consumers

The United States is one of two countries — the other is New Zealand — that allows ‘direct-to-consumer’ advertising, a long-standing practice that became more common in the mid-1980s after the FDA issued new rules. Most advertising was in print. But more television advertising began appearing when some of the rules were relaxed a decade later.

Lom said the ads give consumers a “head start” on knowing about drugs that might be available for their ailments, speeding up the consumer education process.

Surprisingly, 62 percent of physicians, for instance, said they would or might prescribe a harmless, even placebo, treatment to a patient who does not need it but demands it, according to a 2016 poll conducted by Medscape, an online physician education website.

Current rules require that if a drug is named in an ad, information must be included about side effects and adverse reactions. That makes it even more important that drug advertising be visually captivating — if not surprising, say consultants.

Meanwhile, the side effects are glossed over. “The ads describe the risks and at the same time play pleasant music — or show happy images — which helps to distract people from getting the message,” says Dr. Aaron Kesselheim, associate professor of medicine at Harvard Medical School.

Those that do advertise, however, appear to have a handle on the market. Ries, the brand consultant, says it wasn’t just the ad that helped her to remember Lyrica, but the name, too, which was easy to spell and pronounce.

Reis said her mother did take the Lyrica “and it’s helped.” That’s a good thing, says the brand guru who takes pride in looking out for her mother. “The ad spurred the conversation.”

But whether the advertising empowers patients or leaves them vulnerable is debatable.

Many Doctors Say Opioids Are Not The Answer

Leave a comment

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.”

Prescribing Opioids to Seniors: A Balancing Act

Leave a comment

Dr. Carla Perissinotto ImageNational conversation about the opioid epidemic has focused mostly on young people who buy drugs illegally on the street. But the real scrutiny of opioids has also inevitably changed the way physicians are prescribing medications to the elderly.

Over the past decade, a growing number of seniors have been prescribed opioids including hydrocodone, codeine and oxycodone. A recent study found that in 2011, 15 percent of seniors were prescribed an opioid when they were discharged from the hospital.

As concern grows about a national opioid epidemic, however, some seniors now find it harder to get medications they need from doctors and pharmacies. Some medical practices refuse to accept patients already taking an opioid for pain.

Beyond the obvious dangers of addiction, opioids can pose serious risks for seniors. But opioids can also be a critical tool in treating debilitating pain that leaves seniors immobilized and homebound.

Carla Perissinoto, a geriatrician at the University of California San Francisco, says prescribing opioids to seniors is often about helping them maintain their independence and the delicate balancing act of prescribing opioids.

The following questions were asked of Dr. Perissinoto:

Q: How do you decide whether to prescribe an opioid to an older adult?

One of the tenets in geriatrics with prescribing any medication is the idea that you start low and go slow. For someone who is older, there’s a different biology of aging with medications that take longer to metabolize. They affect people differently. For someone who’s younger, you may be able to start at a dose, for example, of 10 milligrams. In an older adult you often have to start at 2.5.

But how I decide really depends on what are this person’s goals? How is the pain affecting their life? What have I tried and what is not indicated for them? 

Ultimately, my goal with using opioids when I have to is, “Can I relieve this person’s pain well enough so that they can maintain their function?” Because ultimately in older adults, their function and ability to live independently is one of the greatest predictors of health. I have patients who unless they take their opioid really cannot get out of bed. And if that small dose of opioid is going to help them get out of bed and move around their house and cook for themselves, then that is absolutely something worth doing. Their biggest risk is going to be if they stop moving and [decline more]. That’s going to have a bigger consequence on their health than prescribing an opioid at a reasonable dose and with close supervision.

Q: What are some of the risks of prescribing opioids to seniors?

As with any person taking opioids, there are real side effects of becoming addicted. Constipation also ends up being one of the biggest challenges, and frankly many of my older adults don’t want to be on opioids because of the fear of constipation. The other thing is, of course, that opioids can be sedating and so they can put people at risk for falls and an increased risk of confusion.

What’s interesting though is that there are some people with dementia who at times appear to be more confused or delirious. And it turns out it can be from uncontrolled pain. So this is where it’s so tricky for geriatricians to figure out, are we giving enough pain medication or not enough? And how do we figure out that balance? And it’s a very close relationship you need to have with the patient to really figure out, “Am I doing the right thing?”

Q: What are some of the other tools you have available to treat pain for seniors?

There are some topical agents that work for some people. Understandably, many patients don’t like taking that many pills, and so the idea of being able to put something on the joint or on the skin is really fantastic. There are other modalities that I think work for people, for example massage. Some people get benefit from acupuncture and chiropractic care.

The challenge is that many of the additional therapies, even some topical therapies, are not covered by insurance. And that actually brings up an interesting point in how we prescribe, in that there are times that I would prefer to prescribe something topical and it’s not covered by insurance, but yet the opioids are. So it also limits you as a physician in terms of “What am I able to prescribe? What can I do for this person that is covered by insurance?” So unfortunately that is one of the unspoken things — that how things are paid for still makes a big difference.

Q: How do seniors fit in with the larger national conversation about opioids?

I do not want to undermine the national efforts which are very real in terms of the serious consequences of opioids. At the same time, for many older adults, these are very reasonable treatment modalities.

What I’m seeing from the national perspective is that because of this real concern about opiate overuse, many patients are being discriminated against. I have patients who are on opioids, they’re on low doses, they’re very stable. There’s no evidence of abuse. And if I’m out of town and they are out of medications, no one wants to refill them. And that actually puts someone at risk for withdrawal. And what happens is someone then comes to the office and requests an opioid refill for something they’ve been on, and they’re labeled as drug seeking.

It’s very sad. And I think that the challenge is how do we keep this national dialogue going so that we educate providers to prescribe safely? How do we educate patients to know how to look for signs of withdrawal and look for signs of overdose? So that we’re not discriminating against people with chronic illness and chronic pain who really do need these medications to function when other therapies have failed.

Q: Are you seeing patients come into your practice for the first time who are taking too many opioids?

I absolutely have received or have started taking care of people that are frankly incorrectly dosed on too many variations of opioids, and it can be risky. And it’s really hard when someone is on them to really try to take someone off and taper down. But it’s something that can be done if there’s significant trust.

I think that part of it is education of providers in terms of safe opioid prescribing. Because of the national concern over opioid use, we’ve swung away where it’s never prescribed … and I think as a result our physicians in training aren’t being taught how to prescribe correctly.

Q: Some people say there are no situations in which opioids should be prescribed long-term. What would you say to them?

I completely disagree. Palliation, which is the relief of symptoms, is something that is incredibly important with older adults. There are many illnesses in older adults that cannot be cured. And if you are trying to maintain someone’s independence, there are very reasonable times where people may be on opiates; osteoarthritis or severe spinal stenosis. Some of those things do not have great treatments and there are times where opioids do have a positive effect on someone’s relief of pain so that they can maintain their function.

I think that unless you have lived [with] pain yourself, it’s very easy to judge and very easy to assume that someone can just get over it. And I hear this time and time again from some of my patients who were being judged … : “I’d like for that person to walk in my shoes and see what it’s like to live with pain and maybe they would think differently.”