chronic pain

RECENT POSTS

Second Opinion: Doc Says Blue Cross Opioid Policy Is Flawed

Amidst concerns over a massive national increase in the use and abuse of prescription painkillers, health insurer Blue Cross Blue Shield of Massachusetts instituted a new policy to reduce pain medication addiction and misuse.

This week The Boston Globe reports that as a result of the new policy, Blue Cross has cut prescriptions of narcotic painkillers by an estimated 6.6 million pills in 18 months.

But Daniel P. Alford, MD, an associate professor of Medicine and director of the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) Program at Boston University School of Medicine and Boston Medical Center, calls the policy “flawed and irresponsible.” Here’s Alford’s response:

By Dr. Daniel P. Alford
Guest Contributor

The Blue Cross Blue Shield of Massachusetts opioid management program was implemented to provide members with “appropriate pain care” and reduce the risk of opioid addiction and diversion.

In a recent Boston Globe report they claim “very significant success” with this program after 18 months because they have cut opioid prescriptions by 6.6 million pills.

Dr. Dan Alford

Dr. Dan Alford

Is this really a measure of success and if so, for whom? It likely saves Blue Cross money but has it successfully achieved their program’s stated goals? Does decreased opioid prescribing mean more appropriate pain care? Does decreased opioid prescribing reduce the risk of addiction or diversion, or does it decrease access to a specific pain medication (opioids) for treating legitimate chronic pain? Is the observed decrease in opioid prescribing evidence that opioids have been overprescribed, as Blue Cross claims, or is it proof that instituting a barrier to opioid prescribing (prior authorization) will decrease prescribing even for legitimate need? Are patients with chronic pain really benefiting from this program? I doubt it.

Adding yet more paperwork for physicians will not improve pain care, decrease addiction or the numbers of accidental overdoses from prescription opioids. Those physicians who are unwilling (or ambivalent) to prescribe opioids even when indicated will use the prior authorization requirement as an excuse to continue not prescribing. Those who are overly liberal in prescribing will figure out the most efficient way to satisfy the insurance requirements for approvals. Physicians who responsibly prescribe opioids – that is, prescribing them only when the benefits outweigh any risks — will be saddled with more administrative burdens to justify their well thought-out treatment decisions.

Some physicians may ultimately decide that prescribing opioids isn’t worth the trouble despite known benefits for some patients. Continue reading

Talking To Your Doctor About Pain

https://www.youtube.com/watch?v=BHQnIittck0&list=PL96EE3EE3F1C6B859&index=1

Chronic pain is notoriously hard to deal with — for both the sufferer seeking relief and the medical provider trying to alleviate a real problem that is sometimes difficult to pinpoint.

One critical issue, according to health reporter Judy Foreman, who just completed a book on pain, is that doctors are often woefully uneducated on the subject:

There’s a good, and obviously sad, reason why physicians know so little about pain: Medical schools don’t teach it. A major study of 117 medical schools from Johns Hopkins last year showed that out of all those years in medical school, med students get a median of only 9 hours of pain education. Even veterinary students get more. It’s high time Senators, Congressmen, medical school deans and other powers-that-be took this to heart.

Last year, hoping to gain a better understanding of how to better treat pain, a U.S. Senate committee held hearings on the topic. Now the Joint Commission, the a non-profit group that accredits hospitals and health care programs in the U.S. has created an animated video featuring little cartoon pain devils and urging patients to talk — specifically — with their doctors about pain. “Describing your pain to your doctor and nurse is important,” the narrator says. “Don’t tough it out.” Suggestions on how to deal with pain include traditional medications, but also acupuncture or massage. (No mention of medical marijuana here.)

Other advice to patients:

–Make sure their pain is assessed by a health care provider;
–Describe the pain they are experiencing to their caregivers; Continue reading

Overdose Antidote: What The Government Doesn't Do, And What You Can

naloxone

(PunchingJudy/Flickr Creative Commons)

You hear a lot these days about the national epidemic of painkiller overdoses. What you don’t hear so much about is what you can do to respond to those overdoses when they happen, much as we learn about CPR or defibrillators for heart attacks.

In an opinion piece just out in the Journal of the American Medical Association, Northeastern University assistant professor of law and health sciences Leo Beletsky and his co-authors argue that the government should do far more to enable the public to fight overdoses. Why doesn’t it? And what can each of us do? He explains here.

By Leo Beletsky
Guest contributor

Now a true national crisis, overdose from opioid drugs like Oxycontin and heroin kills about 16,000 Americans every year. Outranking car accidents, it is now the leading cause of accidental death in many states, including Massachusetts.

Rural and poor communities are particularly hard-hit, but contrary to popular belief, this epidemic does not discriminate: Overdose victims come from all classes, races, and age groups. Deaths afflict both legitimate and illicit users of prescription medications as well as those using street drugs like heroin.

Many of these deaths could be averted. Long-term prevention efforts are needed, but in the meantime, there are some straightforward things we can all do immediately to stop overdoses from turning fatal.

First: From the onset of the telltale signs of overdose, such as shallow breathing and slow pulse, it typically takes 30 to 90 minutes for the victim to die. This provides a precious window of opportunity to save a life. The tragic reality is that people often don’t recognize the overdose in time and thus don’t quickly call 911.

Second: Most people do not realize that once an ambulance has been called, they can help save the victim’s life. The key is to determine if the person is breathing; if not, rescue breathing and CPR should be performed. And ideally, the drug naloxone should be given to the victim.

Leo Beletsky

Northeastern University’s Leo Beletsky (Courtesy of Northeastern)

What is naloxone? Known by the brand name Narcan, it is an overdose antidote, a drug whose only effect is to reverse an overdose from opioid drugs like Oxycontin, Vicodin or heroin. Given via injection or nasal spray, it blocks the opioid receptors in the brain, typically working within about four minutes to revive the victim.

It seems like a no-brainer, doesn’t it? Shouldn’t anyone who takes opioids, or who is close to someone who does, know what to do in the event of an overdose, and keep this potentially lifesaving drug available?

In fact, however, it is much harder than it should be to get and fill a prescription for naloxone, even though it’s extremely safe and has no potential for abuse.

Why? Continue reading

Columnist Judy Foreman On Rampant Under-Treatment Of Pain

Health columnist Judy Foreman

Judy Foreman, perhaps the best-known health reporter in Boston and a nationally syndicated columnist, is now in pain. That is, she is writing a book about chronic pain — titled “A Nation in Pain: Healing Our Biggest Health Problem” –and is deeply immersed in the subject. She has kindly agreed to drop us an occasional post about the world of pain, and here is her first:

There’s a dynamite piece in the Jan. 19 New England Journal of Medicine that I would urge anybody in chronic, severe pain to read.

It’s written by Dr. Philip Pizzo and Noreen Clark, who chaired the committee of pain specialists who wrote an important report last June for the Institute of Medicine, an arm of the National Academy of Sciences. Pizzo is dean of the Stanford University School of Medicine and Clark is director of the Center for Managing Chronic Disease at the University of Michigan.

 

Medical schools barely teach about pain, even though pain is the main reason people go to doctors.

 


In their New England Journal piece, and in the lengthy Institute of Medicine report itself, Pizzo and Clark argue eloquently that under-treatment of chronic pain is rampant in this country, that we have a “moral imperative” to do better and that many patients in severe pain understandably see their doctors as “poor listeners.” (I can vouch for this personally: The first doctor I saw during an 8-month bout of severe neck pain a few years ago suggested my pain was an emotional problem.)

As Pizzo and Clark say, “the magnitude of pain in the United States is astounding.” Continue reading

Photos Make Chronic Pain Visible

If you live with chronic pain, you have vast quantities of company. The estimates range from a few million to one-quarter of Americans in long-lasting pain. But you might never know it. Pain is not visible. There’s no 12-step group for it. And if you’re hurting for long, you’re likely to retreat into isolation rather than reach out to others.

Enter the US Pain Foundation (US as of only this January; it began as the CT Pain Foundation), a volunteer-based group founded by Paul Gileno, a former chef who had to find a new calling after a broken spine left him in constant agony. It runs support groups; does advocacy work; and tomorrow, beginning at noonish, is holding a free-lunch session at the Tufts School of Dental Medicine that features The INvisible Project, which documents in photographs and text the lives of people with chronic pain. (One example is here.)

The project’s aim is to educate others about the lives of people with pain, Paul said: “I think the biggest perception for people who don’t have chronic pain all the time is that if they don’t see it, then it’s almost like they don’t believe it after a while. In the beginning, if you get injured, people say, ‘Are you okay?’ But after a while, that chronic pain stays and it’s a year later and people tend to say, ‘Okay, when are you going to get better?’ Well, I wish I could get better right now but my pain is still there. We’re saying, ‘It’s real and we want you to know this is real.’”

Also, Paul said, “We want to show other people with pain that their new normal isn’t much different than everybody else’s who suffers with chronic pain. We want to show them that it’s okay if you’re home one day and not feeling well, it’s okay if this is all that you can do. We want to show them that this is the new normal and they’re not alone.”

The people featured in the project have diagnoses ranging from arthritis to fibromyalgia to lupus to obscure syndromes few have heard of, but they have two things in common: They’ve been chosen by fate to be physically tortured, and they soldier on.  Continue reading

Therapy Used For Trauma, Chronic Pain Snubbed By Establishment

What does it take for the American Psychological Association to bless an alternative type of therapy?

It’s a question that Harvard Medical School psychiatrist Rick Leskowitz, director of the Integrative Medicine Project at Spaulding Rehabilitation Hospital, has been asking for years.

Dr. Leskowitz sent me an email after I wrote about yoga for treating veterans with post-traumatic stress disorder. He said that another approach, called Energy Psychology, a kind of psychological acupuncture without needles, is “the most impressive intervention I’ve encountered in 25 years of work.” I was intrigued.

From Facebook Fight to Alternative Treatment

One of his patients, Nicole McCarthy, told me that after she was hit by a car — intentionally, by a teenage driver — and suffered a traumatic brain injury, among other damage, Energy Psychology was the most effective treatment to heal her emotionally. McCarthy, a 41-year-old dancer, said the therapy allowed her to talk about the accident for the first time without hyperventilating and crying, and to overcome the deep fear and psychic trauma associated with the hit-and-run. (It occurred after a Facebook feud between her daughter’s teenage friends spiraled out of control). Just one session, she said, “was a life-altering experience for the better. It’s a tool I will use for the rest of my life.”

Dr. Leskowitz cites his own clinical experience and a growing number of studies showing the benefits of the practice. For instance, two recent studies involving combat veterans found that after six sessions of intensive Energy Psychology, the vets show marked relief from their PTSD symptoms.

The APA Just Says No

But the American Psychological Association says the science behind the therapy still isn’t adequate, and it won’t grant continuing education credits for training in Energy Psychology. Continue reading

Pain During Sex? There’s Hope In A Little-Known Treatment Option

About one-third of women experience pain during sex, says a new report. But treatment is available.

About one-third of women say they have pain during sex, according to a comprehensive new series of reports on the sexual lives of Americans published this week in the Journal of Sexual Medicine.

Debby Herbenick, one of the study’s authors, told me that number “surprised” her — she didn’t think so many women would report that kind of pain.

But it doesn’t surprise me — because I’m one of them.

Here’s my story:

Earlier this year, to put it bluntly, I started having pain during sex. For a while, I ignored it, telling myself it was probably just a passing problem that would resolve on its own. It didn’t.

I went to see my fantastic ob/gyn, Beth Hardiman, the woman who delivered my two children, and whom I trust with the most intimate details of my life. She did an exam and told me my vaginal muscles were locked in permanent spasm, like if you gripped your shoulders up to your ears and never let go.

“You need pelvic floor massage,” she said. (You can imagine what I envisioned.) “I’m giving you a prescription for pelvic floor physical therapy.”

Now, I thought I was a savvy health care consumer, having written on the topic as a journalist for the past 10 years. Plus, I’ve had two babies, so I thought I was fairly familiar with the pelvis. Wrong. I had never, ever heard of pelvic floor physical therapy. And I never realized how many complex systems — reproductive, urinary, gastrointestinal, neurological, psychological, and musculoskeletal — can be involved in pelvic pain.

Dr. Hardiman told me that many doctors hadn’t heard of it either. And if they did, they pooh-poohed the field as a bunch of amateurs blithely assigning kegel exercises to their patients. But she said so many of her patients complain of painful sex and related problems that pelvic floor physical therapy, as a specialty, should be far more recognized and respected. She gave me a list of 25 pelvic floor physical therapists in the region. The first five I called were completely booked and not taking new patients.

Then I found Rachael Maiocco, a pelvic floor physical therapist in Chestnut Hill, at the Brigham and Women’s Hospital Department of Rehabilitation Services. There was a three-month wait to see her, but eventually, I was scheduled for eight visits. Continue reading

Report: Smoking Pot Helps Relieve Chronic Pain

Note to chronic pain sufferers: Please Inhale.

Canadian researchers, overcoming significant political and regulatory hurdles, found that when patients smoked marijuana, their chronic pain diminished (their moods improved too, but we probably didn’t need a study for that.)

The groundbreaking clinical trial, with results published in the Canadian Medical Association Journal, determined that:

“Low doses of inhaled cannabis containing approximately 10% THC (the active ingredient in cannabis), smoked as a single inhalation using a pipe three times daily over a period of five days, offered modest pain reduction in patients suffering from chronic neuropathic pain (pain associated with nerve injury) within the first few days. The results also suggest that cannabis improved moods and helped patients sleep better. The effects were less pronounced in cannabis strains containing less than 10% THC.”

In an editorial accompanying the study, Henry McQuay, an emeritus fellow from Bailliol College, Oxford writes: “If patients are not achieving a good response with conventional treatment of their pain, then they may, reasonably, wish to try cannabis. If medical cannabis is not available where a patient lives, then obtaining it will take the patient outside of the law, often for the first time in his or her life. Good evidence would at least buttress that decision.”

This may be easier said than done. A report in The New York Times this week says that even people with prescriptions for medical marijuana are confronting hostile employers. In some cases, they’re getting fired for failing drugs tests even with a legitimate medical reason to smoke pot.