Pain Specialists Urge Stronger Use of Holistic Therapies
August 16, 2011 -- Pain specialists think a paradigm shift in the way chronic pain is treated is needed in Oregon, strongly advocating that holistic therapies replace prescription opiates as the dominant method of treatment.
Prescription opiates such as methadone, oxycodone and morphine have become the most widely used method to treat chronic pain. According to Dartmouth Medicine magazine, there’s been a 347 percent increase of these opiates between 1997 and 2006.
But pain specialists, researchers, and physical therapists argue that prescription opiates are a costly and ineffective method of treating chronic pain. “[It] causes us all a lot of angst,” said Kathryn Hahn, pharmacy manager at the Springfield Bi-Mart, who chairs the state’s Pain Management Commission, at a presentation she gave to the Oregon Health Plan medical directors in June.
According to the National Center for Health Statistics, approximately 26 percent of Americans experience pain that lasts longer than 24 hours. If that statistic holds true for Oregon, then around 940,000 Oregonians suffer from chronic pain. And according to the American Pain Foundation, $100 billion is lost each year due to medical expenses, lost job wages and decreased productivity.
“We need to change our system,” Hahn said. “We're not getting good outcomes.”
Oregon is the only state with a pain commission. In June, the state’s new Prescription Drug Monitoring Program began, requiring pharmacies to report the opiate prescriptions they fill.
But for Oregon to decrease prescription opiate use and increase other therapies, Hahn and others think primary care providers need to be better educated about the effect of opiates, and insurance companies must cover other treatment options.
Chronic pain drastically affects a person’s life
Chronic pain, said Beth Darnall, a pain psychologist at Oregon Health & Science University’s Pain Clinic, lasts longer than three months after the injury is expected to heal. There’s no test that can identify how much pain a particular patient is feeling. In that sense, she said, pain is subjective. “Ultimately, pain is something that the person feels,” Darnall said.
Chronic pain can dramatically alter a person’s life and habits. People may not be able to work, mow their lawn, play with their children, or do other activities. Chronic pain can also cause irritability, depression and anxiety.
Prescription opiates are often prescribed, but can be ineffective
Prescription opiates have become popular because they are an easy solution for physicians, who can simply prescribe them to patients who seek a quick fix for their pain.
Released over time, prescription opiates relieve pain by essentially dulling the nervous system. People are relieved of pain for a short while. But the pain isn’t cured. “Most of the people who come to the pain clinic say it takes the edge off, but it doesn’t take the pain away,” Darnall said.
Anxiety and stress are also reduced because of the drug’s effect on the nervous system. But that has negative consequences. “It makes people reliant on the medication to manage stress, anxiety and other factors in their life,” Darnall said.
Over time, a tolerance develops. “They start working less and less well,” Darnall said. “In a few months, someone is suddenly desperate for stronger medications.”
Opiates are highly addictive, and Hahn said there’s an increasing culture of sharing opiates and people stealing them from family member’s medicine cabinets. “We have prescription drug abuse that’s looming bigger and bigger,” she said.
Side effects of long-term use of prescription opiates are include disruption to sleep patterns, endocrine deficiencies, hyperalgesia (increased sensitivity to pain) and suppression of the immune system, said Catriona Buist, clinical director of rehabilitation clinic Progressive Rehabilitation Associates.
The main concern, Buist said, is that increased use of opiates doesn’t improve a person’s function—which should be the main goal of treating chronic pain.
Pain treatment should increase a patient’s function and quality of life
The paradigm shift Hahn wants to see is from an “analgesia alone” approach to one that’s function-based. Because chronic pain never goes away, as Hahn and others emphasize, treatment should help people manage and learn to live with pain.
“It's about not really curing it, but bringing quality of life back,” said Namita Gandhi, clinical exercise physiologist and founder of the Integrative Movement Clinic, Inc.
Increasing a person’s function can mean enabling them to move, go to work, play with their children, and pursue other activities they did before becoming injured. “Your pain may not go away, but if you can ride your bike with your children or go to the grocery store, then your quality of life has improved,” Darnall said.
The treatment focus is “on improving the patient’s life rather than eliminating their pain,” Hahn said.
There are multiple ways of treating chronic pain. Patients can pursue physical and occupational therapy; stress management; self-hypnosis; relaxation exercises; acupuncture, chiropractic and movement therapy that strengthens and stretches injured muscles, and lifestyle changes in diet and exercise.
Hahn said such treatment methods create objective and verifiable goals, whereas the only standard existing with prescription opiates is whether they relieve pain for short periods of time. Gandhi describes the treatment as more “holistic.”
Integrative Movement Clinic offers a 10-week program offering movement programs, integrated with different stress management techniques, such as reading and relaxation. “Movement can only take you so far,” Gandhi said. “It’s not what you do, but how you do it.”
Insurance doesn’t pay for alternative types of care
Buist said a major obstacle to expanding access of these treatments is insurance companies, which typically don’t pay for integrative treatments and only cover prescription opiates. “There are many times when the only thing covered for a patient is a kind of drug therapy,” Hahn said.
The Oregon Health Plan is limited in what it covers--acupuncture for treating back and pelvic pain during pregnancy, as well as for migraine headaches. And, of course, methadone and prescription opiates.
She faults the Oregon Health Plan for only providing coverage for methadone and other opiates. “For Medicaid patients, there are almost no services complimentary to prescription opiates, or alternatives to them,” she said. “All they have available is methadone.”
During Hahn’s presentation at the medical directors meeting, Mike Shirtcliff, president and director of Advantage Dental, admitted “we have more work to do in this area.”
But many medical directors became defensive. “This is a problem because of physicians” and not necessarily the drugs, said Dr. Chris Kirk, medical director of Mid-Valley IPA. “I think doctors would tell you that patients are there, asking for them, demanding.”
Dr. John Sattenspiel, senior medical director of Agate Healthcare, worried that if providers began selectively prescribing opiates to patients, and routing others to other types of therapy, the move would “put our license in jeopardy because we aren’t adequately addressing pain. It takes one disgruntled patient to complain to the Medical Board of Examiners.”
The Division of Medical Assistance Programs (DMAP) is currently reviewing the coverage of chronic pain treatment. A report will be submitted during the 2012 legislation session in February.
Increasing the level of education providers have about prescription opiates and their effects is critical, Hahn said. “We want [prescription opiates] to stay; we just want more education on how to use it.”
Providers can fail to properly assess patients, assess risk for drug abuse, notice aberrant patient behavior, identify goals of therapy and not check in with patients.
The National Pain Care Policy Act, part of the federal Affordable Care Act, will improve training for healthcare professionals, by increasing research funding for pain and improving access to pain care.
Many hope the Prescription Drug Monitoring Program will help stop people from abusing prescription opiates, and increase awareness about how they’re being used. “It remains to be seen,” Darnall said.