Prescription for Abuse: Next Steps to Improve Pain Care for Washingtonians

DEC. 21, 2011
ByAlex Cahana, M.D.
Special to KCTS9.org

Alex Cahana

Pain is hard. Hardest for those experiencing it, but also difficult for the well-intended healthcare professional, the educator trying to teach the difference between pain as a symptom and pain as a complicated disease, and for payers, administrators and policy makers trying to make informed choices.

But recognizing the problems are not enough. How do we ensure patients receive compassionate care in a way that is appropriate, effective, safe and financially sustainable for society at large?

There is no one way, but there are multiple ways that, taken together, can make a difference.

In 1961, John J. Bonica, father of modern pain medicine, opened the first academic pain clinic at University of Washington that became a world model for the diagnosis, study and treatment of pain. In 2008, proud to lead the legendary ‘Bonica’ clinic, I found myself stepping into a storm where dozens of providers asked to transfer care of their pain patients because ‘there was nothing else left to do,’ medical students decided not to pursue a career in primary care because they felt that ‘pain is too hard’ and Washington was one of eight states where deaths from accidental overdoses from opioids exceeded deaths from motor vehicle accidents. That required a new way of thinking and acting to improve pain care.

Pain care, as Dr. Bonica taught us, is a treatment plan devised by a multidisciplinary team that may sometimes include opioids, but always includes listening to the patient, determining the patient’s personal goals and individually tailoring a variety of medical, exercise, mind-body treatments, and healthy life choices.

We pay particular attention to the most vulnerable patients since the sickest and most disadvantaged are frequently those who receive the most pain medication, oftentimes because that is what their healthcare professional knows and what insurance will cover. As a result, these patients receive simply too much medication to be safe and to function well. There is no ‘good’ or ‘bad’ pain medication. There is only medication that is prescribed appropriately and safely, or not.

Our Telepain consultation video service connects dozens of healthcare professionals weekly for guidance and support. In 2011, more than 1500 physicians and other healthcare professionals discussed hundreds of patients and received hundreds of hours of free Pain education.

We have developed an innovative system for measuring and tracking key outcomes important to pain patients. We evaluate their mood, sleep, progress, intensity of pain and amount of relief they have experienced. These questions are systematically captured, tracked and analyzed so we can make more informed treatment choices for individual patients and provide advice for the greater pain population.

The UW Medicine Pain Center’s model of coordinated, collaborative and measurement-based care has been shared with medical practices regionally and nationally, with the Department of Defense, Veterans Administration, state agencies and large employers who are keen to develop value-based treatment plans for pain.

The new Washington State law 2876 offers guidance to healthcare professionals and defines the best time to seek expert help when patients do not do well. It addresses the need for TeleHealth, encourages providers to exchange prescription information and mandates the need to measure pain, mood and function at every patient-provider encounter. That provision, rarely mentioned or appreciated, is exactly what the 2011 U.S. Institute of Medicine (IOM) report on Pain Management refers to as ‘a needed cultural transformation.’ Measurement is key to understanding patients and the effectiveness of treatments.

Striking balance between access to affordable pain care and reducing risks of treatment-related harm is a delicate one.

Pain is hard. As a society we need to shift our thinking and recognize the complexity of this disease. We are off to a good start in this state, but there is much more work to be done.

Alex Cahana is Chief of the Division of Pain Medicine at UW Medicine.

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03/22/12

Dear Dr. Kahana and all,

I watched the show and following discussion with great interest as I have been taking MS-Contin twice a day for nearly 9 years and hydrocodone/apap for break through pain. I suffered a crushing compression fracture and ever increasing stenosis of L1 and S1 vertebrae. I saw several orthopedic surgeons who advised me that the surgical options would have low probabilities for improving the pain and disabling mobility I experience. They said to hold off until walking and standing become almost impossible. Use pain meds for the interim years. It was very difficult to eventually find an Internist who worked with me until we found a regime which made the pain more tolerable however this has done nothing to improve my freedom of motion or anything like normal activity.
I do not seem to react like most people to opiates. I experience unwanted stimulant effects from morphine and especially fentanyl transdermal patches. Other side effects are itching scalp and excessive tickling inside my nostrils but the extreme wakefulness is the most difficult side effect I experience. I am a 60 year old man who incurred this injury in 1998 and it took almost six years to get almost enough pain relief to at least not be talking about my pain all the time even though I can not do my own dishes and other ordinary house work.

The reporting, the laws and what seems like fear tactics upset me because just because some wish to use drugs to get high they end up getting the spotlight while real pain patients suffer by being denied medications which work or at least help to reduce their suffering.
I lost my brother in 2004 to an Oxycontin over dose so I know better than most how big and how serious this problem can be but the facts are that those who want to get high can find heroin or any other illegal drugs they want. We had the illegal drug problem before Oxycontin was introduced and when physicians are frightened that their prescribing of opiates isn't worth the required paperwork and unwanted over sight.
As a result there are more legitimate severe chronic pain patients going untreated adequately than there are those using diverted legal opiates. The aging of the demographics means there will be more people with pain until the baby boomer generation has moved on.
I think this issue is a "soft target" for sensational journalism and a platform of a few self-aggrandizing physicians enjoying being in the spotlight and exercising so much influence over the decisions of their non-pain specialists peers and legislators which merely causes more to seek out pain clinic help where they will find little of it.

There is a big difference between your written remarks above about striking an appropriate balance between how Pain Clinics treat severe chronic pain sufferers and your tone.

There seems to be a presumption of guilty of drug seeking behavior for new patients. This field seems to be dominated by extremely conservative physicians who play all kinds of silly alternative treatments.

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