Mrs. Smith is an 81-year-old female. She worked a long time doing very physical work and is now on a fixed income and comes to my office with chronic pain. X-rays show she has degenerative arthritis in her hips, knees and lumbar spine. She has taken Norco twice a day for years and has been able to be very stable on this. She has always been compliant with her medications. She has not lost them or had them stolen. She lives with her husband, and they use a safe where they keep their medications. The patient has done well with acupuncture and massage in the past but is not able to afford these, and her insurance doesn’t cover these services. The main reason she was referred to our clinic is that her primary care provider is refusing to prescribe her medications as they do not want to prescribe long-term opioids.
I work in interventional pain management, and we provide a lot of interventional services that can help decrease pain for a lot of patients. We also take care of people who are on chronic pain medications. With the opioid “crisis” there have been a lot of providers who no longer believe in pain. Pain has gone from the fifth vital sign to a non-existent symptom which has left a lot of patients who are in pain to suffer.
We’ve come to a point where we have found that there is an issue with opioid medications, but no one wants to come up with a solution. We have options for alternative treatments that have been found to help people with chronic pain, but unfortunately, they are expensive and are not covered by insurance. For someone on a fixed income, it is much less to spend twenty-five dollars on a copay for a month of Norco than the $80 a week for a massage.
We’ve decided overprescribing of opioids is an issue, and there are a lot of groups who we can point the finger at. In the news, the blame is often put on the providers who prescribed the medications. For the most part, they were just trying to take care of the patients and the “fifth vital sign.” We can blame the patients who seek drugs and abuse the opioids, which in large part is the issue but they are still getting the medications from somewhere, so we can control that by not prescribing the medications. Or we can blame big pharma for marketing the medications and getting it into the medical offices.
I think we can all agree that opioids are an issue, but where do we go from here? First, we need to realize that pain is still a symptom and is something that is treatable. That does not mean that every patient that comes into the ER or goes to the dentist to have a dental exam needs to leave with an opioid prescription. I’ve had injuries and have had teeth pulled, and I have never required an opioid but was always given a prescription just in case. Many of these acute injuries don’t need opioids to be treated, but if a patient has chronic pain and has been stable on their medication we don’t need to cut them off just because “we no longer prescribe.”
Pain is something that is still very treatable for most primary care providers. “But you’re the pain clinic, isn’t that what you do?” Yes, that is what we do but does every patient who has a blood pressure of 140/80 need to be sent to cardiology? We see a lot of patients who are in a lot of pain and are in need of more medication than two Norco per day.
Current CDC guidelines recommend clinicians prescribe the “lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.”
There is no recommendation that clinicians stop prescribing opioids for all their patients and no longer treat patient’s pain. Of course, we must be judicious when prescribing and make use of urine drug screens and your state’s prescription drug monitoring program to monitor patient compliance. There are also screening tools such as the SOAPP-R and ORT to see who may be a high-risk patient.
As far as alternative treatments, we can continue to recommend these. But until insurances start covering these it’s unlikely that patients will be compliant with them. It’s much cheaper for the insurance to cover a monthly prescription compared to weekly treatments. If we want to really do something to help patients with chronic pain, we need these treatments to be covered.
The opioid issue is a real problem but that does not mean people no longer have pain. As providers, we should continue to look for ways that we can treat pain but we also must help educate patients on what pain is. Instead of pointing the finger at other people for causing the problem, we all need to work together to find a solution to the problem. And that solution is not to stop treating pain, so when Mrs. Smith comes into your clinic don’t turn her away because you “don’t prescribe opioids.” Look at the patient and see if there is good reasoning for her to be on a treatment and make your decision based on the individual, not on all the outside factors.
T. J. Matsumoto is a physician assistant who blogs at PA-Cents.
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