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How can we incentivize doctors to change their prescribing patterns?
In preparation for this week's discussion, I wanted to share some resources that might be of interest. We encourage you to share additional resources on this important topic, as well as any questions you'd like to see our panel address over the course of the week. Looking forward to a great discussion!All resources for this Expert Panel can be found at ghdonline.org/opioid-epidemic/resources
Link leads to: http://www.huffingtonpost.com/healthline-/treating-pain-in-the-mids_b_10153542.html
Link leads to: http://www.npr.org/2016/08/01/488269407/patients-seek-out-alternatives-to-opioids-in-treatment-of-chronic-pain
Link leads to: http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
In medical training, we quickly learn heuristics to simplify complex and time-consuming decision making, including reflexive prescriptions for each common patient complaint. Nausea = Zofran (ondansetron), Constipation = Miralax / Senna, Cough = Dextromethorphan, Edema / Water Retention = Lasix (furosemide), etc. Unfortunately, a similar quick fix reponse that gets learned is Pain = Opioids (e.g., Vicodin/Norco, Oxycodone, if not IV Dilaudid and Morphine).While arguably these can be useful for short-term use in acute pain or their more conventional use for terminal (cancer) pain, we're now paying more attention to the unforeseen consequences of the pendulum swinging too far. Particularly for (non-cancer) chronic pain syndromes (e.g., low back strain, arthritis, headaches, fibromyalgia), there is not great evidence to support long-term opioid prescribing. Moreso, there are many alternatives to consider before resorting to acceptance of opioids and their respective adverse effects (assuming they are acknowledged at all).There's no simple recipe that fits every patient case, but if there is not an underlying problem that can be directly addressed (e.g., hip replacement), some common non-opioid alternatives I approach chronic pain with:Over-the-Counter, but option for higher prescription doses:- Acetaminophen (Tylenol)- NSAIDs: Ibuprofen (Motrin), Naproxen (Aleve)Neuropathic Agents (for cases with more "nerve pain" rather than typical somatic and visceral pain)- Gabapentin, pregabalin- SNRIs: Duloxetine, VenlaxafineMuscle Relaxants- Cyclobenzabrine (Flexeril)Injections (joints or trigger points)- (Cortico)SteroidsNon-Medication Options (likely even more important, though access sometimes limited)- Heat vs. Cold Topical Treatments- Physical Therapy- Massage and Aquatic Therapy- Chiropractic or AcupunctureOne of the biggest frameshifts that helped me approach patients with chronic pain is to not even set "elimination of pain" as a goal, especially when it will likely not be achievable in a chronic case. Instead, the more useful goal is improving function (with a secondary goal of relative pain relief). If a patient's pain is impairing their ability to sleep, to work, or even just to walk across the street to engage in their daily activities, then it is worth trying any tool we have to help gain some of that function back. Prescribing more medications thinking it will help a patient "feel better," but which doesn't allow them to function any better, can easily lead one down a dangerous rabbit hole.
I think your approach is a rational one. Particularly reframing that elimination of pain is not the goal. In the same way physicians are retraining thought processes patients need to retrain theirs. What does pain mean and when is it useful. Teaching patients that pain has three levels if you will - the local my arm hurts - the spinal - transmission of pain signal and finally at the brain - interpretation of pain. When I use other medications I preface with that - attacking the pain from another direction. This often helps patients appreciate changing the conversation.When I tell patients they have more serotonin receptor in their gut than their brain they listen. It helps shift that the SSRI might help their pain. Living in a state that does allow medical marijuana topical preparations also work.
I am not an expert in the field but I believe there may be a number of challenges ahead of dealing with chronic pain - It seems often difficult to pinpoint the exact origins of the pain (what has gone wrong with the body). Therefore current analgesia chemical therapies may provide undesirable off-target effects that exacerbate the pain situation.Do the current knowledge provide enough information about the identity of the target and the specific effect of the chemicals we used to treat chronic pain?
The biggest challenge is that the untoward effect of opioids is knocking out the body's natural balance of dealing with pain. We have endogenous opioids so when we flood the opioid receptors with medication the balance is lost - thus the increasing need for medication (tolerance) and often increasing pain (hyperalgesia). This is the biggest lesson from the epidemic. This is the reason that opioids should not be used for most chronic pain and the hardest lesson to teach patients who have been taught all these years they can have these drugs and have become dependent on them. Talking to patients about that and engaging them in that discussion has for me been the most successful way of explaining why a prescription won't be forthcoming or why we are weaning.
I dwelled on the topic of alternative therapies to treat pain, and the resources posted by Marie, where patients seek alternatives to medicine. This struck me …how about Meditation for Pain Management I am not a clinician. However, I am a patient who used to suffer from severe headaches. I started practicing mind-fulness meditation, ten years ago (more as a spiritual purpose) and my headaches are gone…How is the idea of “ Meditation as a prescription -Twice a day or As needed” for pain?As an adjunct therapy? Would that reduce pain intensity, and its related psychological consequences, and improve thequality of life? Is it cost-effective? I follow the system of meditation, called as “Heartfulness” which is offered free of cost for the people interested in practicing it. Interestingly enough the Spiritual Guru who opened up an ancient Hindu form of Yoga (RajaYoga) to the modern world into a heartfulness program is – Rev. Kamlesh D. Patel. Relevant for this discussion is: Rev. Kamlesh D. Patel is a successful Pharmacist from New Jersey ! . He followed Raja Yoga for the most of his adult life before he was selected as a spiritual guru a few years ago. I spent last few days in Ashram in NJ with him. It was an absolute bliss... We have a network of Ashrams all over the world, and we meet every Sunday for a group meditation. The Ashrams are simple , harmonious places to meditate. They are located all over the world, from Denmark, Romania, South Africa, USA, France, UK, Germany to name a few. If any one wants to practice,/explore the Heartfulness either as a treatment plan or to reduce chronic pain improve the quality of life please write to me :My email is
Link leads to: http://en.heartfulness.org/video/
Mind body techniques, meditation, guided relaxation etc are all useful for treating pain. As is exercise (my personal one). All are incredibly powerful at releasing the body's natural opioids.
Hi Cathleen,Yes, I agree with exercise .However, just curious if I may , while exercise sweats out all the negative physical stress,Is there a difference (if any how /meditation affects the body Vs. the Exercise).To me exercise calms a stressful mind, but Meditation also offers Bliss...A moment of thoughtless ness..It strengthens my mental capacity. Any thoughts..
In my opinion, meditation, yoga, and exercise all constitute different levels of oxygen-consuming activities, which can channel energy to the mind to boost our self-healing abilities. Increasing the level of endogenous pain modulators may be one of them.
I often struggle with this question and tend to believe that pain should be treatable with these alternative methods, as you all have discussed. However, I have personally seen family members struggle to overcome their chronic back pain, trying all modalities such as physical therapy, non-narcotic medications, yoga and meditation without success. The pain is simply debilitating, and my loved ones are forced to give up the activities they once enjoyed, and endure this decreased quality of life. I am an advocate against overuse and abuse of opioids, but I also acknowledge that we have these medications for a reason and that is simply because some forms of pain we are unable to adequately control without them. My belief is that we must utilize opioid medications as strictly a short term therapy, and make all attempts to address the underlying problem. Whether it be a surgical intervention to repair the damage, or a lifestyle modification, such as cessation of smoking to promote healing, we must continually re-evaluate and redesign these individualized care plans to prevent long term use of opioids.
Smoking has been 100% shown to increase pain particularly back pain. So when patients come in (and where I am smoking rates are high) that is the first thing we work on. Particularly if they want the prescription.Absolutely this is not necessarily going to be an either or for everyone - and as a bupenorphine provider I have moved some patients over to that. Particularly back pain is truly inappropriately treated with opioids on a chronic basis and we as clinicians have done patients a disservice using them for long periods. As a previous poster said more appropriate therapies are gabapentin and tricyclics as they address neuropathic pain. If the pain is more arthritic then nsaids are the mainstay. And for back pain core strengthening is critical.
I agree with Chistina; that back pain can be debilitating. Also like Cathleen had said, Core strengthening is a way to go. And of course, for such debilitating pain opioids are the important solace-no discussion. I know an elderly woman who had a spinal injury and is mostly confined to bed. She keeps her positive spirits with meditation and positive thoughts. What I am trying to say that mindfulness as an adjuvant therapy may be a great value to improve the quality of life. Cant resist noticing “Yoga Rooms in the airports”. It is such a simple thought to stretch during long flights. How normal was it 15 years ago? A good 20 mins in a day to connect with oneself will improve self-awareness, self-regulation improves compassion, and strengthen ourselves . Finally it may improve drug seeking behaviors.
The all time best research for medication use was described in a Lancet 2009 edition using a combination of low dose gabapentin and nortriptyline: placebo controlled, double blind cross-over study with remarkably low p values. Oddly, it takes two weeks to "kick-in," and there is no risk for tolerance. Generally, it will reliably decrease pain on average from a 6 to a 3 baseline. Also, if the person wants to do a trial off, there is no rebound. If the pain level eventually returns, the relief reappears just as before. The study was done, very precisely, at the University of Manitoba (Canada). I have always wondered why the study ended up being published in Great Britain. Unfortunately, I am suspicious.
I fully endorse the advantages of meditation and yoga and exercise programmes.I have also had good results though not miraculous with herbal supplements like magnifera indica,acacia catetchu and cissus quadrangularis.Enzyme preparations like bromelain help.Homeopathic preparations like Hypericum perforatum are also useful.Besides physical forms of therapy like Pulsed electromagnetic field therapy are useful.I have only recently experimented with the last mentioned and would love to be associated with trials on such forms of therapy.Maybe we should have a non biased non commercial portal to educate clinicians on non drug options and offer advice on possible options for individual cases.
I agree with you Sandeep. Non-drug and non-commercial no risk drug options are so valuable and worth discussing.
While those have a place, I think it is important to realize that a patient coming in who has been dependent on opioids - often for years - is NOT going to be appeased by being told to go home and meditate.Patients who have phantom limb pain, patients who have pain from trauma (I have patients who were victims of home invasions - one had his face smashed in with brain damage) patients who have spinal trauma are not necessarily going to respond to non pharmaceutical treatment.
Cathleen's point is well taken.Things are different when dealing with a patient already on opiates but a lot can be done before a patient is put on opiates.Further patient acceptance of meditation as treatment is not very good. However physical forms of therapy luke PEMF and herbal analgesics need to be popularised and urgent steps taken to develop widely available low cost solutions. .As a clinician I shall be happy to be part of such a team.
At some point, the folks with chronic pain almost always evolve into a state of mental weariness or conversion pain. At that point, a person's extended family and their family traditions become part of the problem or part of the healing. These situations commonly involve multi-factorial interacting causes of unstable health, as in auto-immune processes of rheumatoid arthritis or Reiter's Syndrome, neuropathies especially autonomic as in Trigemenal neuralgia, and contagion such as Shingles, recurring skin infections or recurrent bronchitis. Underlying all of this is the poorly maintained Primary Healthcare capacity of our nation's healthcare to offer meaningful and trustworthy "caring relationships" as the basis for the management of complex care plan needs...for anyone. The level of uncertainty, day in and day out, is profound for these people. Ultimately, it becomes a spiritual problem underlying their level of despair, worsened by the mixed messages they receive from the fractured dimensions of our nation's "common good" for a long time.
I certainly agree that under severe pain, opiates are the source to go. We cannot undo Medicine and go back in Timemachine to 3000 BC to 100,000 years BC.What I was trying to allude, to strengthen people’s will to avoid pill seeking behavior, Improve quality of life, emotion self-regulation for a sub-set of population who might be benefited from such avenues. As Paul mentioned it is only a “Part of healing-coping”. But before even reaching that point, we need to sensitize people as part of living- I mean spend quality time in a day for yourself. Exposure to the concept of mind-self regulation when young and healthy. Though I practice Meditation, I never looked into scientific evidence on this topic.Here are some quick finds from open source. Kindly share any interesting reads. Now I want to look deep here, :1. Mind-Body Therapies in Children and Youth: SECTION ON INTEGRATIVE MEDICINE, Pediatrics Sep 2016, 138 (3) e20161896; DOI: 10.1542/peds.2016-1896 2. The Emerging Role of Mindfulness Meditation as Effective Self-ManagementStrategy, Part 2: Clinical Implications for Chronic Pain, Substance Misuse, andInsomnia. Mil Med. 2016 Sep;181(9):969-75. doi: 10.7205/MILMED-D-14-00678.3. Prevalence, patterns, and predictors of meditation use among US adults: Anationally representative survey.Sci Rep. 2016 Nov 10;6:36760. doi: 10.1038/srep36760.4. Mindfulness Interventions Delivered by Technology Without Facilitator Involvement: What Research Exists and What Are the Clinical Outcomes?. Mindfulness (2016) 7:1011–1023DOI 10.1007/s12671-016-0548-2.
Hi, I'm an American doctor working in the DR Congo. Unfortunately, we have no opiates here (I have heard that they are illegal, though I need to confirm this). The only options provided by our hospital are tramadol, acetaminophen, ibuprofen, and occasionally ketorolac injections. Amitryptaline is available in the community. Gabapentin is harder to find and very expensive. I've heard that ketamine (either in drip form or even IV formulation taken orally) can be a very effective pain control option (particularly in palliative care patients). Do any of you have experience using this medication for pain control?Patrick LaRochelle
PatrickWe are using Ketamine for chronic and acute pain. I am attaching 2 articles. We generally use in a multimodal combination with other non opiate analgesics . My experience is with acute adult post surgical pain and 10 mg /hr IV intra op and post is approximate conservative dosing. One of these articles addresses local administration . Oral , intranasal also has effect. Oral dose 3-5x IV...but can titrate to effectiveness.Adequate pain management has been neglected topic in developing health systems. Rwanda has begun a palliative care program , but they do have morphine and pethidine, as well as non opiates. If you message me I can give you the contact email for the physician who directs the palliative program.
May bea visit to a resource limited hospitals like in many parts of Nepal, where there are unavailability of drugs (except for NSAIDS) could sensitize some prescriptioners on restricting instincts of overuse.