Doctors face opioid dilemma

Undoubtedly, most doctors don't want to contribute to theopioid abuse epidemic sweepingthe nation. But they also want to keep their patients satisfied.And often, the only way to satisfy a patient is to give him hisfix.

In addition to the human instinct to ease a person's pain, atleast in the short term, doctors are under pressure to prescribepowerful painkillers from a provision of the Affordable Care Actthat partially bases Medicare payments to hospitals based onpatient satisfaction.

Patient satisfaction surveys are only one of a number of factorsthat shape a hospital's Medicare reimbursement, and the surveystake into account a number of satisfaction measures, includingnoise and wait times, but they also ask patients to rate how wellthe provider was able to manage his or her pain.

Consciously or subconsciously, doctors are going to beinfluenced by the grading system, Steve Diaz, an emergency roomdoctor as well as chief medical officer of AugustaMaine's GeneralHealth, told Kaiser Health News. And although the payments are onlylinked to hospitals, not physicians, it is common for hospitals tolink physician pay to their performance on such report cards.

“No one will overtly say, 'I'm doing this to not get a badscore,” But in the back of their mind … and knowing they'll bepublicly rated, I think it leads to making that subconsciousdecision.”

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“Legislation alone won't end this epidemic, but workingtogether with the community, we can fight back with a multifacetedapproach that prevents drug addiction before it begins and offerstreatment and recovery to those who need a helping hand and achance to heal.” – Rep. Tim Walberg (R-MI)

Indeed, notes Kaiser, a 2014 survey of 150 doctors found thatroughly half said they feel pressure to prescribe painkillers based onsuch performance ratings.

At the same time, the federal government is telling physiciansthat they have been prescribing far too many opioids. In a newguideline on opioid prescriptions released in March, the Centersfor Disease Control says doctors should much more closelyscrutinize requests for opioid prescriptions from patients and thatit should closely monitor patients on painkillers for signs ofabuse or addiction.

“Nonpharmacologic therapy and nonopioid pharmacologic therapyare preferred for chronic pain,” states the first of 12recommendations from the CDC. “Clinicians should consider opioidtherapy only if expected benefits for both pain and function areanticipated to outweigh risks to the patient.”

Medical groups are urging the feds to rethink the patientsurveys, and the government appears to be listening. A spokesmanfor the Department of Health and Human Services told Kaiser that itis considering re-writing the survey to focus more on theinformation the doctor provides the patient about pain management,rather than the patient's satisfaction with the outcome.

– Jack Craver

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“This is a disease, this is a chronic condition that has to beinterrupted and treated and prevented if possible.” –Hillary Clinton

Seniors facing a painful retreat from opioid treatment

Chronic pain and opioid drugs combine a nastycondition with an equally nasty treatment. For many Americans,treating pain with narcotic pharmaceuticals has become a habit, oneencouraged for years by the medical profession.

But now, as Paula Span writes in the New York Times,the nasty couple may be breaking up.

As media and medical professionals continue to track the growing“opioid crisis,” suddenly what was once a panacea for the sufferingof many seniors is now being attacked as the enemy. Using opioidshas been rebranded as a dangerous method that makes the elderlylazy, dependent and incapable of following safer treatment programsthat don't include opioids.

Span notes the irony of the chronic pain-opioid evolution. Priorto 1999, chronic pain was not officially considered to be atreatment priority for physicians, who tended not to prescribepainkillers to patients complaining of chronic pain.

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Most common drugs involved in prescription opioidoverdoses: methadone, oxycodone, hydrocodone

Nearly one-third of opioid prescriptions acquired by employeesthrough their employer-backed insurance are being abused.

In that year, the Veterans Administration (now the Department ofVeterans Affairs) cited chronic pain as one of five key “vitalsigns” of patients, which increased the pressure on doctors totreat pain with opioids. Hospitals and clinics began to beevaluated on how well they managed patients' chronic pain, andopioid prescriptions increased dramatically.

Today, as the federal government reverses course on treatingpain with opioids, many doctors and their patients are hooked onthe treatment.

But the tide is turning. The Centers for Disease Control andPrevention came out with new, more-restrictive guidelines foropioid treatments. States are cranking out their own laws to limitopioid use, and a reclassification of some of the drugs makes themharder to come by.

Rather than prescribing painkillers, physicians are now beingtold to prescribe therapy and healthier habits, such as betterdiets and more exercise, to control pain. Good luck with that, Spansays. “Some of their doctors are going to get an earful when theysuggest different medications or nonpharmacological alternatives,”she writes.

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94% of those in treatment for opioid addiction turn to heroinbecause prescriptions are 'more expensive and harder to obtain,'according to a 2014 survey.

Seniors may have cause for concern if their physicians turn on adime to replace their current meds with any of the new drugs comingon the market designed to augment or replace opioid use. Span notesthat the side effects of some new drugs are serious and could domore harm than good.

With the national focus on deaths related to opioid overdoses,seniors with chronic pain will be forced to change the way theytreat the aches and pains of growing old. And, Span warns, thatcould be a frustrating and expensive shift until a new anti-painparadigm emerges. For instance, cognitive behavioral therapy hasshown positive results with some pain patients.

“But not enough practitioners offer alternatives like cognitivebehavioral therapy, and insurers (including Medicare) generallywon't pay for them,” Span writes.

So, not only will new treatment methods need to be explored, butinsurers will have to be convinced to help seniors pay for them.And that's almost as nasty a combination as chronic pain and opioiddrugs.

– Dan Cook