Articles by JCS

Opioids for Dummies

Word count: 1484

Opioid Prescribing for Dummies

Joel Cooper, DO, Medical Bag,

"First, they tell us we're not treating our patients' pain sufficiently. We are encouraged — nay, exhorted — to do a better job at it.

Then they tell us we're treating it a little too well.

It seems that every few years, the opinion pendulum swings one way or another regarding opioid prescribing. But the latest swing of that sharp-bladed pendulum is threatening to cut off the heads of doctors who are a little too generous with narcotic pain relief.

The treatment of pain in America has become politicized.

Consider the facts, and you'll quickly see why all of this leaves doctors on the front lines of patient care baffled, perplexed and dumfounded — in a state of stupefaction.

We need some guidelines to help us along. We need Opioid Prescribing for Dummies."

This commentary by Joel Cooper, DO, illustrates the delusion the medical world remains about pain management. If not pain pills, ESIs and back surgery, they are mystified or, as he wrote, “in a state of stupefaction.”

To help Dr. Cooper and his medical colleagues with their confusion, let’s help him get real about the facts surrounding the chronic pain problem:

  • Most MDs/DOs are poorly trained in MSDs.

Dr. Scott Boden admitted this inadequacy. “Many, if not most, primary medical care providers have little training in how to manage musculoskeletal disorders.”[1] Many other researchers also confess medical primary care physicians are typically inept in their training on musculoskeletal disorders,[2] prone to ignore recent guidelines,[3] and more likely to suggest spine surgery than surgeons themselves.[4]

“One can make the argument that the most perilous setting for the treatment of low back pain in the United States is currently the offices of primary care MDs,” according to Mark Schoene, editor of The BackLetter, a leading international spine research journal [5]

  • What they’ve been taught hasn’t worked—opioids, ESIs, and surgery.

Mark Schoene also deems the rash of drugs, shots, and spine surgery as the “poster child of inefficient spine care.” He also states that “such an important area of medicine has fallen to this level of dysfunction should be a national scandal.”[6]

  • 30% of opioid prescriptions are for LBP alone and chronic MSD pain constitutes 70% of opioid usage.

This point was made clear in a 2009 study, “Trends in De-facto Long-term Opioid Therapy for Chronic Non-Cancer Pain,”[7] that found opioid users mainly suffered from the following:

1. Back pain                               29.9%        

2. Extremity pain                               22.6%

3. Osteoarthritis                                 11.1%

4. Fractures, contusions                 6.4%

5. Neck pain                                 5.2%

6. Headache                                 4.1%

  • These cases should be referred to DCs first as guidelines now suggest.

This situation was well expressed by David Elton, DC, and Thomas M. Kosloff, DC, co-authors of “Conservative Care: Ensuring the Right Provider for the Right Treatment”: [8]

“Research and guidelines are consistent and clear. We don’t need another guideline, we do need to help patients receive treatment from providers aligned with research/guidelines.”

Unfortunately, this information about the pandemic of chronic pain and best practices will fall on deaf ears among the medical community. The disconnect between MDs/DOs and the research is a huge chasm that they refuse to bridge due to pride, prejudice and power.

They are also suffer burnout according to Dr. Cooper:

"Doctors Are Busy, to Say the Least

A quick review of the literature will show that doctors are seriously overburdened. Call it “burnout,” call it abuse, call it whatever you want, but few people in their right minds would say that doctors are slacking these days. Nor would anyone dispute that doctors are treating dramatically increased numbers of patients."

Obviously MDs need our help. If it weren’t for the historical chirophobia, these beleaguered MDs would certainly benefit by referring these patients to competent DCs. But that won’t happen as long as political medicine has its say because there is too much money at stake.

Researchers Scott Haldeman, DC, MD, PhD, Simon Dagenais, DC, PhD, and Jaime Caro, MD, in their article, “A Systematic Review of Low Back Pain Cost of Illness Studies in the United States and Internationally,” determined the total U.S. costs attributable to low back pain could be up to $624.8 billion, which is substantially higher than previous estimates.[9]

Legislators Rise to Challenge

Just as medical practitioners are clueless about nondrug alternatives for chronic pain, so are our legislators. For example, the following article appeared this morning in the Macon Telegraph:

Senate bill aims to tackle painkiller overuse, abuse

BY MAGGIE LEE mlee@macon.com

ATLANTA

At the state Capitol, some new legislation is taking aim at the use and abuse of the strong painkillers that lead to addiction for some Georgians.

Addiction for many people starts with a prescription for a powerful, but legal, “opioid.” That’s a group of drugs that includes oxycodone. Some patients get hooked and eventually turn to another drug in the same family: heroin.

One new plan from a powerful Republican state senator involves trying to make it easier to stop that progression.

“It’s an omnibus bill that addresses not only the heroin overdose epidemic but (also) prescription meds,” said state Sen. Renee Unterman, R-Buford, author of Senate Bill 81. She’s also chair of the Senate Health and Human Services Committee, and she chaired an opioid abuse state Senate study committee.

Unterman wants closer state regulation of Georgia’s 70 methadone clinics: places that offer the synthetic drug that can help people beat an addiction to opioid drugs. The details about setting up minimum standards for such clinics are set up in her bill, along with Senate Bill 88, by the powerful Senate Rules Committee chair, Jeff Mullis, R-Chickamauga.

“The majority of them are very good, but there’s a small percentage that are very bad,” Unterman said. She said some clinics don’t work to get people off methadone. “Because they’re making $400 to $600 a month” by supplying people with the drug, she said.

But some clinic operators have argued that people can live a normal life while using methadone, and that moving people off methadone should not be lawmakers’ priority.

Unterman’s bill also requires all opioid prescriptions go into a state database, part of what’s called the Prescription Drug Monitoring Program. Doctors would be able to see if a patient has recently gotten an opioid prescription. “What it does is prevent doctor hopping. It prevents these legal drugs from becoming street drugs and sold at exorbitant prices,” Unterman said.

The monitoring program has the potential to be an important part of the effort to reduce prescription drug abuse, the president of the Medical Association of Georgia, Dr. Steven M. Walsh, said in a written statement. But the association doesn’t support that part of the bill because, Walsh wrote, “Physicians should not be required to check the PDMP, the bill covers an impractical number of substances, and the penalties for physicians are unreasonable and punitive.”

He also said doctors report regular glitches in the system. But the association does support another part of the bill — permanently allowing over-the-counter sales of naxolone, a drug that can reverse heroin overdoses.

If the ACA or GCA had an effective PR program to inform legislators of the latest research and guidelines supporting our brand of  nondrug care, we would appear to be a big part of the solution they seek. 

Considering Life U. is less than ten miles from the state capital, it is shocking chiropractic care isn’t a foregone conclusion. Indeed, someone is asleep at the helm—either the PR department at Life U. or the GCA’s lobbyist, or perhaps the bad image left by Big $id upon the legislators.

However, as you can read, chiropractors are not on her radar as a possible solution and we remain the “elephant in the state senate” as a proven treatment for much of this chronic pain and opioid problem.

State Sen. Renee Unterman, R-Buford, author of Senate Bill 81, mentioned the biggest obstacle she faces:

“She said some clinics don’t work to get people off methadone. “Because they’re making $400 to $600 a month” by supplying people with the drug.”

Of course, she can also expect pushback not only from Medical Association of Georgia, but also from Big Pharma considering opioid painkillers for back pain brought in $17.8 billion, and OxyContin alone made $3 billion in 2010.[10] By 2015, Big Pharma spent $3.7 billion on DTC television campaigns and $5.2 billion overall including magazine, newspaper, radio, outdoor and cinema ads.

Editor Mark Schoene. “Aggressive drug marketing was, of course, a major driver of the opioid overtreatment, addiction, and mortality crisis. It has played a role in up to 500,000 deaths.”[11]

Dr. Joel Cooper agreed with Sen. Unterman when he wrote: “The treatment of pain in America has become politicized.”

Considering the massive amount of money involved in the back pain crisis, and the perpetual resistance from the medical monopoly, is there a political solution to bring our position to the press, public, and legislators?

What can we expect from our state and national organizations to do on this matter?

 



[1] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28(2003):524-525.

[2] Elizabeth A. Joy, MD; Sonja Van Hala, MD, MPH, “Musculoskeletal Curricula in Medical Education-- Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/ 11 ( November 2004).

[3] PB Bishop et al., “The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) part I: A Randomized Controlled Trial On The Effectiveness Of Clinical Practice Guidelines In The Medical And Chiropractic Management Of Patients With Acute Mechanical Low Back Pain,” presented at the annual meeting of the International Society for the Study of the Lumbar Spine Hong Kong, 2007; presented at the annual meeting of the North American Spine Society, Austin, Texas, 2007; Spine, in press.

[4] SS Bederman, NN Mahomed, HJ Kreder, et al. In the Eye of the Beholder: Preferences Of Patients, Family Physicians, And Surgeons For Lumbar Spinal Surgery,” Spine 135/1 (2010):108-115.

[5] The BackLetter, volume 30, number 10, 2015

[6] U.S. Spine Care System in a State of Continuing Decline?, The BackLetter, vol. 28, #10, 2012, pp.1

[7] Denise Boudreau, PhD, Michael Von Korff, ScD, Carolyn M. Rutter, PhD, Kathleen Saunders, G. Thomas Ray, Mark D. Sullivan, MD, PhD, Cynthia Campbell, PhD, Joseph O. Merrill, MD, MPH, Michael J. Silverberg, PhD, MPH, Caleb Banta-Green, and Constance Weisner, DrPH, MSW. “Trends in De-facto Long-term Opioid Therapy for Chronic Non-Cancer Pain,” Pharmacoepidemiol Drug Saf. 2009 December; 18(12): 1166–1175. doi:10.1002/pds.1833.

[8] Optum. Conservative Care: Ensuring the Right Provider for the Right Treatment, 2012.

[9] Simon Dagenais, DC, PhD, Jaime Caro, MD, Scott Haldeman, DC, MD, PhD

A systematic review of low back pain cost of illness studies in the United States and internationally, The Spine Journal, 05/2008; 8(1):8-20

[10] Rafia S. Rasu, BPharm, MPharm, MBA, PhD; Kiengkham Vouthy, PharmD; Ashley N. Crowl, PharmD; Anne E. Stegeman, PharmD; Bithia Fikru, PharmD, MPA; Walter Agbor Bawa, MS, PharmD; and Maureen E. Knell, PharmD, BCACP, “Cost of Pain Medication to Treat Adult Patients with Nonmalignant Chronic Pain in the United States,” Vol. 20, No. 9 September 2014 JMCP Journal of Managed Care & Specialty Pharmacy

[11] Be Aware of Drug Advertising! BackLetter: May 2016 - Volume 31 - Issue 5 - p 60

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