Responsible Pain Management
Physicians look beyond pills to help chronic pain patients
As the opioid crisis deepens in Alaska and the nation, a growing amount of misinformation about the laws, regulations, and recommendations impacting primary physicians and pain management specialists abounds.
“There's a lot of misunderstanding and misconception—even at the level of physicians—as to what is legislated and what is suggested,” explains Heath McAnally, MD, MSPH, a board-certified anesthesiologist, pain physician, and addictionologist at Northern Anesthesia and Pain Medicine in Eagle River. McAnally also co-authored the 2017 American Society of Interventional Pain Physicians opioid clinical practice guidelines and wrote a textbook on the subject for Springer Nature, a research, educational, and professional publisher.
“We've got this dual epidemic going on in this country right now with Institute of Medicine telling us that 100 million Americans suffer with chronic pain. Well, that number is increasing and so is the number of people on opioids,” McAnally says. “Clearly, if you just look at it just from a prevalence of disease standpoint, we haven't helped.”
State and Federal Legislation
In Alaska, the most recent legislative attempt to combat opioid addiction came last year when Governor Bill Walker signed into law HB159, which passed both the house and senate with sweeping, bipartisan support.
“I introduced this legislation as a part of our multi-pronged effort to fight the opioid epidemic facing Alaska, and I’m incredibly pleased to be able to sign it today,” Walker said at the signing. “One death resulting from opioid abuse or misuse is too many, and we must tackle this issue head-on as Alaskans. HB159 is an example of healthcare providers, legislators, and Alaskans pulling together to build a safer state as a community.”
In February of that year, Walker declared a public health crisis in order to combat the state’s opioid epidemic.
“This disaster declaration is an important first step in addressing our public health crisis, which has devastated too many Alaskan families,” Walker said. The declaration established a statewide Overdose Response Program, enabling wide distribution of the life-saving drug naloxone, a medication designed to rapidly reverse opioid overdose.
In addition to strengthening reporting and educational requirements for healthcare providers, HB159 limits first-time opioid prescriptions to a seven-day supply, though exceptions can be made if there are circumstances where it’s unreasonable to ask a patient to return in a week to refill a subscription. In much of the Lower 48, this possible loophole for abusing the law would be minimal. However, the rural nature of Alaska presents plenty of reasonable exceptions to the prescription limit.
On the federal level, since the Harold Rogers Prescription Drug Monitoring Program (PDMP) mandate (which provides funds to states that establish PDMP systems, though does not specify any action that must be carried out based on information collected) went into effect, there has been very little legislative action, McAnally notes.
However, physicians’ practices are governed by more than federal and state law.
“Most of what is happening at a national level is advisory oversight,” McAnally says. “Professional societies and even some governmental organizations, such as the Center for Disease Control and Prevention [CDC], put out a big statement in 2016 saying we have a huge problem.”
The CDC guidelines provide recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.
Information on the CDC addresses when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; as well as assessing risk and addressing the harm of opioid use.
The CDC has been tracking chronic pain issues and opioid abuse for decades. The 2016 guidelines, which are not law, note that an estimated 20 percent of patients with non-cancer pain symptoms or pain-related diagnoses receive an opioid prescription.
“In 2012, healthcare providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills,” the guidelines state.
To create the guidelines, the CDC basically distilled a consensus from experts throughout the nation, McAnally explains.
“The guidelines are basically saying: This is how we feel chronic opioid therapy should be used. But that's not law, it’s expert opinion.
“Having said that, we as physicians are also judged in accordance with what is called standard of care. And we do our best to police ourselves as well. Just because something isn't law doesn't mean it isn't important. These guidelines are all important.”
Aside from legislation and clinical guidelines, there is also public sentiment.
“The pendulum has swung quite a bit over the last ten to fifteen years where prescribing opioids is kind of taboo behavior right now,” says McAnally, who considers himself a conservative when it comes to issuing prescriptions.
Multiple Methods of Management
“There are lots and lots of different disciplines that have managed pain for over half a century. In other words, you've got physical therapists and chiropractors; you've got acupuncturists and naturopaths; you've got pain psychologists.” Among physician specialty pain management practices, McAnally says that traditionally they fall into one of two categories known colloquially as “pill mills” or “block shops.”
Pill mills have ended up in the limelight, due to their tendency to lean on opioid prescriptions in an attempt to manage chronic pain. Block shops, on the other hand, are practices that essentially minimize the use of prescribed medication. These practices rely more on injections and other medical procedures to manage pain.
McAnally denounces the pill mill approach, pointing out that some 90 million Americans received an opioid prescription last year; 10 million to 15 million are misusing opioids; and at least 5 million are addicted. However, he also suggests that the block shop approach hasn’t done much to mitigate the problem either, with the federal government reporting one out of three Americans suffering with chronic pain.
“This isn’t working. First of all, just from a disease standpoint, but secondly, from an economic standpoint,” he says.
Health economists from Johns Hopkins University have reported that the annual cost of chronic pain is as high as $635 billion a year. That number, however, includes economic costs, such as lost productivity.
“Our leaders are recognizing that we're going to bankrupt the healthcare system, if not the nation, if we don't change how we manage pain,” McAnally says.
However, attempting to limit opioid prescription to minimize the risk of abuse, addiction, and overdosing does not mean that general practitioners and pain management clinics are unable to help patients suffering from acute or chronic pain. Opioids are simply one tool in their ever-growing toolbox.
In fact, the Alaska Native Medical Center Pain Management Clinic doesn’t prescribe opioids at all.
“So in general, pain medications for chronic pain should be handled through a primary care provider that has a relationship with the patient and understands their full health picture, not via our pain management clinic,” says Fiona Brosnan, the director of marketing and communications Alaska Native Tribal Health Consortium.
Others practices, such as AA Spine & Pain Clinic, which serves Fairbanks and Anchorage, are more willing to consider opioid prescriptions as an option.
“We always consider all treatment options for each patient’s needs. Prescription medications are only one possible option in our tool box,” says Aaron Wollrich, the marketing director for AA Spine & Pain Clinic. “Pain specialists have the ability to utilize a multitude of treatments, such as regenerative therapies, epidural injections, facet injections, nerve root blocks, cryo- or radio frequency nerve ablation, neuro stimulators, and pain pumps. Our providers always weigh the risk and benefits of all applicable treatment options.”
The introduction of HB159 has had a minimal effect on the majority of patients treated at AA Spine & Pain Clinic, Wollrich says.
“We prefer to offer non-opioid treatments where they will be effective for our patients. Certain patients who have extreme conditions, such as multiple failed back surgeries or massive traumatic injuries, may be offered a neuro stimulator or pain pump as a treatment option,” he says. “We work with each patient to achieve a manageable pain plan.”
As AA Spine & Pain Clinic doesn’t make any money from prescribing medications, the changes have had no impact on their bottom line, Wollrich says.
McAnally says the changes have also had a minimal impact on his business. In fact, if anything, there has been a slight uptick in referrals from general practitioners who are becoming increasingly wary of prescribing opioids.
Educating Doctors, Patients, and the Public
“I'm very restrictive on how I prescribe opioids, and I was doing this before. It's not that I'm reading the weather vane and changing my practice,” McAnally says. “I actually left the OR and went into full-time pain management because I perceived, had been perceiving for several years, that we're having a problem here with how we're managing pain. And that we're getting people hooked on opioids. And their pain isn't getting any better.”
McAnally points toward the National Institute of Health’s National Pain Strategy, which was commissioned by the US Department of Health and Human Services.
“It's still in a research and development stage. Implementation hasn't started at a national level. But, some of the key points of this national pain strategy—what we’re being told we need to do—involves a ton of education,” he says. “We're being charged with educating not only patients but also providers, because a lot of frontline clinicians in primary care have absolutely no idea. There is a reason that we have pain specialists—it's so complicated. Just like cardiology or neurosurgery isn't in the purview of primary care. Chronic pain isn't really either.”
Part of that education for clinicians and the public is taking a holistic approach to treating pain through the biopsychosocial model, which attributes medical issues to the intricate, variable interaction of biological factors, psychological factors, and social factors, McAnally explains.
“For example, there is excellent evidence out there that stress leads to coronary diseases and can even cause cancer. There are so many examples of this,” McAnally says.
“What I've learned in fifteen-plus years of doing this is that if I do not address someone's psychosocial components, their emotions, everything, there is no way I'm going to be able to help their physical complaint.”
Another component of the National Pain Strategy is focusing on preventative medicine: a refocus on changing lifestyles to prevent pain from happening rather than trying to react to it. This comes down to helping patients create healthy eating, sleeping, and exercise habits.
However, for some patients opioids might still be the best solution. Nonetheless, a bigger picture must be established before prescribing, notes McAnally.
“When we're talking about drugs with high-abuse liability like opioids, we, as physicians, have to be thinking beyond just this individual patient. We've got to be thinking from a public health standpoint. And there's a huge problem with diversion of these drugs,” he says.
Whether further restrictions on opioids are handled through federal or state legislation, the original source of their popularity—pain—isn’t going away. So neither are pain management clinics, though the way pain is managed continues to evolve.
Looking ahead, Wollrich says there is potential in the development of regenerative therapies, such as platelet rich plasma and stem cell treatments.
“Unfortunately, they are relatively expensive and are not typically covered by insurance companies,” Wollrich says. Still, he says the move towards regenerative and alternative therapies in Alaska is quite strong.
“As regenerative therapies further develop, they will likely be a huge part of treating pain in the near future.”
Isaac Stone Simonelli is a freelance journalist and former managing editor for the Phuket Gazette.