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Wake Up People!

Wake Up People!The State Government of Tennessee believes that our citizens are prescribed more pain relieving medication than any other State in the nation. Is that true? I do not know. I do not know how governmental authorities arrive at their conclusions. And I really do not wish to attempt to find all of the potential data resources that exist which potentially influence the numbers game related to prescription narcotics.Every so often we hear news about a physician or physicians who were arrested for dealing prescription drugs to the general population. It is not common, but I recall it has happened in Shelby County a few times. I did not know those doctors, nor did any of my physicians’ colleagues know them. Those drug dealing doctors were arrested and perhaps some of them went to prison for drug trafficking.In an effort to curb the substance abuse problem correlated with the high use of prescription pain medication, the State of Tennessee has promulgated new guidelines about the proper dispensing of pain medication to patients who suffer from chronic pain for one reason or another. It should come as no surprise that pain is one of the most common symptom that drives people to seek a physician, especially acute pain which is signaling that something within the body is out of accord and possible emergent therapy is needed. The State recognizes that this kind of pain should be treated aggressively. Anyone with a broken arm, laceration, dental procedure or operation will experience some intensity of pain. Some people have a high tolerance to pain, others a very low tolerance to pain. We all have experienced physical pain and our personal tolerances to pain dictate how we think others feel pain. Why? Because of the theory of mind that human possess.When I was an emergency medicine resident in the early 1980's, a study from Harvard was released about the risk of addiction or abuse of pain medication in people suffering from an acute episode of pain. As I remember, they reviewed the charts of two thousand people who needed an emergent care episode for one reason or another and followed their medical history for five years or more. Only four patients out of those two thousand treated patients abused their medication after their first pain medication prescription. That was about 0.2% of those who were treated. I assume there have been many more studies that have focused on this same issue over the years, and perhaps the percentages have increased with our society's increase to the intolerance of pain in general, but I still believe the incidence of becoming addicted to pain medication after an isolated use of pain medication is extremely low.The Tennessee Governor wants desperately wants to curb the use of pain medications for chronic pain conditions. This is one big black eye on our State as a whole. There are probably a number of ways to reduce the number of patients on chronic pain medication for the treatment of chronic pain. The State created a steering committee which included several governmental agencies and a number of physicians who specialize in pain management. Not all pain specialists are the same. Some are trained in anesthesia, others in neurology, psychiatry and physical and occupational medicine. They all have different worldviews about pain. Anesthesiologists tend to believe in blocking the pain with procedures, psychiatrists might be more inclined to treat the depression associated with the pain, neurologists may wish to treat pain with medications that are effective against seizures and occupational physicians may be more interested in treating patients who have gotten hurt on the job. There are specific pain syndromes such as failed back syndrome which means the patient has had numerous back surgeries to correct an anatomical disturbance in their back in an effort to relieve pain and none of the invasive operations worked.Regardless of a pain specialist's orientation to pain, they only see patients for the component of pain related to their infirmity. The treatment of their infirmity is left up to the specialist or generalist who has been associated with the care of the non-pain related medical disturbance. This can be effective in some cases and ineffective in others. My patient care philosophy is to care for the patient as a whole, using consultations from specialists as a guideline to the most current standard of disease oriented treatment. But sometimes a specialist overlooks the other therapies of which a patient is engaged. The specialist may not note drug interactions, innate unique individual pharmacogenomic patient characteristics, adverse effects or the overall cost of their prescriptions into the mix of the patient's established therapeutic adventure. I think pain specialists have a necessary place in the care of patients with chronic unrelenting pain especially since chronic pain increases in its intensity as a disease progresses. Many pain specialists believe that chronic pain cannot be completely relieved in many patients because their clinical experience in treating their patients pain have been minimally effective. I am not a pain specialist since the tools in their medical bag are quite limited: pain blocks, topical compounded creams, non-narcotic drugs approved for pain control and opioid medications. Opioid medications are difficult to use effectively, over time patients become tolerant to the therapeutic effects of opioids and their dose will increase, the drugs themselves have chronic side effects, and depending on your pharmacogenomic profile you may metabolize them extremely rapidly or be a poor responder to the effects of the drugs. What makes matters worse, these drugs have a incredible demand on the illicit drug market making opioids subject to diversion more than any other medication I know of. The State's guidelines are very specific about what a physician can and cannot prescribe. For example, primary care physicians will no longer be allowed to prescribe methadone to any of their patients. Those patient receiving methadone will have to be under the care of a pain specialist who specializes in dispensing methadone; not all pain specialists do. Furthermore all of our patients who receive a monthly opioid medication for pain control will have to sign forms associated with their use of opioids, these forms disclose what the rules are for their use of opioids and by signing the forms and they agree to submit to at least two random drug screens per year. Fortunately we can do the drug screens in our office using a simple enzyme-mediated assay method for twelve drugs. If there is any discrepancy between the patient's medication and our in-house drug test, we will need to send a sample to a forensic laboratory for further analysis. I envision that diagnostic adventure to be a rare occurrence. Patients will need to be seen every three months and any sign of drug abuse or diversion will trigger immediate clinical action. The State is very strong in their opinions on what actions are necessary depending on what clinical deviation has transpired.A handful of patients will be referred to pain specialists for consultation because they exceed the 120 morphine equivalents monthly allowed by the State. I understand this consultation is to assure that the patients are being cared for in a safe and effective manner. If the pain specialist approves the established treatment, they will simply return the patient back to our office for care, making sure we comply with all of the other guidelines associated with their care. I believe this change by the State signals a turning point in the practice of medicine. I can understand the need to standardize the use of prescriptive pain medications because there appears to be an abuse of the honor of prescribing these medications within the physician healthcare community which has reached national attention demanding Federal intervention. I am all in on this one. Shame on our healthcare industry for letting the problem get so out of hand, and I am one minute part of the system.I hope that other specialists through insurance companies and State Medical Boards do not begin to limit general practitioners to standardized guidelines or strategies that they themselves (insurance companies and their paid medical experts) have created because advancements in treatment of most diseases will come to a halt. It will take generations of physicians to change the standards proposed by these self-proclaimed experts. Patient's will suffer and be subjected to a specialist's myopic traditional occidental allopathic ways of managing illness. We all know everyone doesn't require statins because they are useless preventing illness from undiagnosed heart disease; that sugar, fruit, beans and starch are poison to a diabetic patient and medication will not reverse that fact; and you should have a choice in who manages your illness with compassion and dedication to you as a patient, not some standard guideline that a profiteering insurance company created to save money and/or limit care or by some doctor who is more concerned about managing his physician extenders (Family Nurse Practitioners and Physician Assistants) than managing your individual disease.Wake up people! The healthcare industry is changing and not for the better. Do something to make sure you always have a choice? Vote.Doc
Posted by Amanda Sanders at 9:06 AM
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