- The Washington Times
Thursday, December 27, 2018

Doctors in Kansas knew their pain patient — older, overweight and medicated for a back injury — was at a crossroads after he fell at home and landed in the hospital.

His opioid treatment appeared to be making him foggy and affecting his motor skills, so physicians at Hutchinson Clinic said it was time to wean him off the powerful painkillers.

“He was extremely resistant. He thought it would be the end of his life,” said Dr. Verlin Janzen, the clinic’s chief medical information officer. “I just told him he didn’t have a choice.”

It was the right move. With a regimen of physical therapy and the occasional Tylenol as his only pain pill, he is sleeping better and needs less help to move in and out of the wheelchair he now uses.

“He feels 100 percent better off the opiates,” Dr. Janzen said.

The medical profession is re-examining its extensive use of opioid painkillers under the glare of an addiction crisis that is killing tens of thousands of Americans each year. Legions of people got hooked on prescription medications and then turned to cheaper heroin and deadly synthetics such as fentanyl.

“The roots of this crisis are embedded in the practice of medicine and prescribing practices that were at times too cavalier. A generation of providers dispensed these medicines too liberally and were slow to address the signs of misuse and addiction,” Food and Drug Administration Commissioner Scott Gottlieb said ahead of a summit this year for chronic pain sufferers.

Federal regulators and the medical profession are trying to strike the right balance between cancer patients and others for whom opioids may be their only way to function — and fear being stigmatized as “addicts” — with efforts to reel in the use of potentially addictive medications when alternatives might work.

The FDA said it developed a blueprint on the safe use of opioids that drugmakers must provide to prescribers, and it started an innovation challenge to develop alternatives to manage pain.

In south-central Kansas, doctors at Hutchinson decided to develop an opioid policy after hearing about similar efforts elsewhere at a conference in 2017. Though other places have much worse overdose rates, the Kansas doctors didn’t want to let the nationwide epidemic flourish in their community.

“If we weren’t ahead of the game, a problem that wasn’t as big of a problem here was going to filter down and be a problem,” said Dr. David Gleason, a surgeon. “We can start a policy now to prevent it now.”

The policy focuses on patients who have taken opioids regularly for 90 days or more to provide relief from back injuries, knee pain, chronic arthritis, fibromyalgia and other ailments.

Some of them do well on simple alternatives such as ibuprofen, though the off-ramp from opioids often demands weight loss, physical therapy and exercises that improve flexibility and range of motion or strengthen the patient’s core.

In any given set of 10 patients, at least half will typically be amazed by the transformation. For starters, they are no longer afflicted by the grogginess or constipation that comes with opioid use.

“It’s totally changed their life, and they feel a lot better,” Dr. Janzen said.

In Atlanta, Dr. Erik Shaw said one of his patients at the Shepherd Spine and Pain Institute is a woman in her 50s who broke her back in a fall and relied on opioids for years.

Yet the institute was able to slash her opioids use by 50 percent, and doctors hope to get to 75 percent soon. The patient tried a device known as a spinal cord stimulator, which emits electrical signals to parts of the spine to target pain.

“Her quality of life and function is dramatically better today than it was last year,” Dr. Shaw said.

The psychological component of tapering off opioids is critical. Motivation and the realization that they may need to cope with some pain in their lives are key.

Besides therapy, professionals say, cognitive therapy and mindfulness techniques can help patients relinquish their pills.

“It’s definitely not an easy situation for patients to deal with. For a very long time, that’s how they’ve learned to cope with pain,” said Javier Ley, director of clinical programming at Valley Hope, a drug treatment center in Norton, Kansas, where some in recovery still need non-narcotic treatment for pain.

The success these groups have found prompts the question of how the epidemic reached this point.

Some doctors said the advent of opioid medication in the 1990s were marketed as effective and not addictive, a claim that turned out to be false.

At the same time, The Joint Commission, a nonprofit organization that accredits hospitals, started to view pain as the “fifth vital sign.” Clinicians began to put an emphasis on patient satisfaction — opioids were a means to that end — to avoid poor performance scores.

“The pressure is on physicians to do what the patients want,” Dr. Janzen said. “We have just been led down that path.”

Policymakers and clinicians hope better days are ahead.

Doctors wrote fewer opioid prescriptions for the fifth year in a row in 2017, slashing their use by more than 55 million — a 22.2 percent drop — since 2013, said a report by the American Medical Association.

Doctors also more than doubled their use of prescription drug monitoring programs in 2017 from 2016 so they could see whether patients were shopping for opioids elsewhere.

“I do think the tide is definitely going in the right direction,” said Dr. Shaw, adding that some of the conversation has pivoted to which alternatives insurers will cover. “There are a lot of options outside of opioids that can be helpful for people. I think the question is the cost of these things.”

America’s Health Insurance Plans, the main lobbying group for insurers, said it is working with federal and state leaders and doctors to make sure patients can access treatments with proven track records.

Coverage for alternative therapies is based on evidence, not cost, it said. For instance, occupational therapy and physical therapy have strong evidence bases while measures such as acupuncture and yoga have thinner records.

Devices such as spinal cord stimulators, which helped Dr. Shaw’s patient, still depend on the insurer, which will review the scientific evidence — including clinical trials — to decide whether they should be covered.

“There is a growing body of research that suggests that interventions like physical therapy, massage and acupuncture may be effective in treating chronic pain,” said Cathryn Donaldson, spokeswoman for America’s Health Insurance Plans. “Several plans have integrated coverage of these interventions into their coverage policies.”

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