At the 2018 CLM / Business Insurance Workers’ Compensation Conference, a panel discussed non-opioid alternatives to pain management. The speakers included:
- James Atchison, DO – Medical Director Pain Management, Shirley Ryan Ability Lab
- Caryn Feldman, PhD – Associate Professor Department of Physical Medicine and Rehabilitation, Shirley Ryan Ability Lab
- Shana Margolis, MD – Attending Physician, Shirley Ryan Ability Lab
- Melissa Roy – Manager, Nurse Case Management and Pharmacy, AF Group
Appropriate use of opioids and the challenges of opioids:
- Opioids may be appropriate initially on very severe injuries, but not sprains and strains. They are also appropriate initially after surgery.
- Our pharmacy benefit managers monitor all opioid prescriptions to track for inappropriate prescribing. They look for multiple physicians prescribing the medications. We have a Pharm D on staff and they will reach out to the treating physician if they see something inappropriate.
- Long acting opioids are not appropriate in the initial stages of a claim. With acute injuries the short acting medications are best.
- Physicians do not receive much training on pain medications in medical school. Because of this, using your expert peer advisors to assist in educating the physicians are important.
- A psychological evaluation is required for things like a spinal cord stimulator, but there is no such evaluation required for the prescription of opioids. I’m not suggesting everyone that is prescribed opioids should have a psychological evaluation but we know psychology plays a significant role in pain and if the opioids are continuing beyond the short-term you should get the psychological evaluation.
- Most people with a chronic pain problem also have issues with anxiety. In order to get the pain under control it may be necessary to treat the anxiety.
- Too often people are using the opioids for inappropriate reasons, for example to help them sleep at night. These medications should not be taken as a sleep aid as they in fact can interfere with sleep. If the patient is having a problem sleeping then you should consider prescribing a medication to assist in that.
- Focus on function. If medications are not improving their function then they should not be taking them. No one should be taking opioids and just sitting on the couch.
- Encourage physicians using opioids to check the PDMP (prescription drug monitoring program) in their state regularly to ensure the patient is not seeking other opioid prescriptions. Many states only require the physician to check the PDMP before the first fill.
- Any pain procedures, such as epidural injections, should cause a decrease in medications not an increase.
Alternatives to opioids:
- Psychology is a large component of pain. The practice of pain psychology is extremely effective and getting a pain psychologist involved in chronic pain claims is essential.
- The psychologist has to convince the patient that their role is to help them understand and cope with their pain. You are not denying that they have pain or telling the patient it is “all in their head”.
- There is over 40 years of objective clinical data supporting the success of multidisciplinary pain management programs. These things work well, but most payers, patients, and even physicians know very little about them.
- Patients are usually initially skeptical about things like mindfulness, biofeedback and other alternative treatments. The clinician has to help the patient understand how successful these programs are and encourage them to just give them a try. Point out that what they are doing now is not controlling their pain.
- Despite having other tools available to assist in their pain control, patients are often still hesitant to let go of their opioids. This tends to creates anxiety which increases the pain. You have to reassure the patient constantly and wean them slowly.
- Weaning people off higher doses of opioids is very challenging and doing an outpatient wean is a slow and very difficult process for the patient. Most often, a rapid inpatient detox program works best in these situations. However, you need to be prepared to deal with the anxiety issues associated with the weaning and provide both psychological counseling and perhaps even medications for the anxiety. The anxiety is a very normal and expected reaction.
- Everyone needs to understand weaning off opioids is a difficult thing for patients, even if they are fully committed to doing this. Be supportive and understanding.
- Work with the patient on setting goals for restoring function so they can get back to their life. Getting them moving again, back in the community, and back to work are a very important part of the rehabilitation process.
- Relaxation techniques are one of the most powerful tools for patients in managing chronic pain.
- Most patients with chronic pain never had good coping skills and it has impacted their lives for years but they don’t realize this. Helping them learn better coping skills can not only help with their pain, but with their overall happiness in life.
- Fear of re-injury is common with chronic pain patients. They are afraid movement will increase pain. Teaching pain patients better posture, ergonomics, and movement will help them learn how to move properly which lessens the chance of doing something to worsen their condition.
How do we change the way physicians approach pain?
- For a physician, writing a prescription is easy and will satisfy a patient. We need to educate patients, physicians, and society as a whole that pain is a normal human response and having an expectation of never having pain is not realistic.
- In smaller communities with limited resources, physicians feel all they have available to them is the drugs.
- Improving insurance coverage and access to alternative pain management treatment is also very important. Insurance providers both in group health and workers’ compensation have been hesitant to approve these treatments while at the same time they will quickly approve prescriptions.
- Telemedicine could have a role in helping to provide pain psychology programs to underserved communities.
- We are seeing a decrease in the number of people being prescribed opioids and in many states these prescriptions are being limited in terms of the number of pills and the lengths of the prescriptions.
- In the old thinking, if the patient did not get sufficient relief from pain medications, the response was to increase the medications. The new thinking is that if a patient does not get relief from medications then the use of the medications is likely inappropriate and you need to be considering alternatives or at least different medications. Doing more of the same thing that does not work is how we got into this mess with opioids.
How do we better educate injured workers?
- Nurse case managers provide an excellent opportunity to work directly with the patients to discuss their pain medication and the potential alternatives treatments.
- Educational letters to injured workers can help them better understand the appropriate use of opioids and the negative side effects of these drugs.
- From an education standpoint, we need to make a clear distinction between prescription opioids and the illegal use of things like fentanyl or heroin. There is a tendency in the media to lump all these things together. Dealing with chronic pain patients taking prescription medications is a very different thing than dealing with someone who is abusing illegal narcotics.