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http://www.register-herald.com/news/pennsylvania-pain-doctor-shares-thoughts-on-opioid-epidemic-ideas-for/article_dfd799e5-e64a-5faf-aab9-684e6342eb81.html

Pennsylvania pain doctor shares thoughts on opioid epidemic, ideas for change
By Wendy Holdren Register-Herald Reporter Jul 24, 2016
Pennsylvania pain doctor shares thoughts on opioid epidemic, ideas for change
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A Pennsylvania pain doctor says the opioid epidemic ravaging the country is the result of a perfect storm — one of oversight from the medical system, lack of education, restrictive insurance companies and an instant gratification minded society.

• Oversight

Dr. Bruce Nicholson, the director of Pain Specialists of Greater Lehigh Valley in Allentown, Pa., said the system has been more reactive than proactive about monitoring patients on pain medications.

According to the Center for Disease Control and Prevention, more people died from drug overdoses in 2014 than in any year on record. The majority of drug overdose deaths (more than six out of 10) involved an opioid. Since 1999, more than 165,000 people have died from prescription opioid overdoses.

Local, state and federal officials have been working since the release of the staggering numbers to curb the problem.

Nicholson said the guidelines issued by the CDC for patients and prescribers, will be helpful, but changing prescriber behavior will be challenging.

The CDC encourages the use of non-opioid therapies (from exercise and cognitive behavioral therapy to non-opioid medications), to "start low and go slow" (prescribe the lowest effective dosage and only the quantity needed for the expected duration of pain), and to follow up regularly to monitor patients prescribed pain medication.

"The key is to understand when you may be doing harm to a patient," Nicholson said.

• Lack of Education

When he was in medical school in the 1980s, he said, "We didn't even talk about pain."

The medical community started talking about pain in the 1990s, but the focus strengthened in the 2000s, what Nicholson calls "the decade of pain."

Pain became "the fifth vital sign" and patient satisfaction surveys were based largely upon a patient's alleviation of pain. Doctors followed suit, Nicholson said, mostly because they wanted what was best for their patients.

Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled, according to the CDC. Deaths from prescription opioids have also quadrupled since then.

Patient pain was treated with a "superficial, broad brush approach," Nicholson said, instead of focusing on individual patient needs.

"The idea that people couldn't become addicted was based on very, very, very, what I would call imprecise observations of small numbers of patients."

That mindset "really took a lot of clinicians down the wrong road," he said. And many prescribers today have not yet changed that behavior.

To encourage change, Nicholson recommended additional state mandates for continuing education, especially courses on responsible prescribing and better monitoring patients on opioids.

• Insurance Restrictions

Instead of taking an opioid medication, Nicholson said many patients would be better served by multi-disciplinary measures.

Injections, cognitive behavioral therapy, long-term physical therapy are all alternative treatment options, depending upon the patient, that Nicholson might recommend.

"All types of therapy can show significant benefits, but the problem is getting insurance to pay for one."

Nicholson said most insurance companies cover a short course of physical therapy and medication.

"That's the extent of 'adequate care' by most insurers," he said.

And those medications, oftentimes opioids, can be easily misused or abused by patients. Many abuse-deterrent formulas, such as crush-proof pills or controlled release, are now available, but the most common form of misuse is simply overtaking medication.

"That's one area where it's hard to eliminate that problem," Nicholson said, adding improved vigilance from all involved parties and better education is needed.

• Societal Issues

"We've become an instant gratification, pill-taking society," Nicolson said. "We take more than any other country in the world."

According to a 2011 report from the United Nations Office on Drugs and Crime, the U.S. makes up 5 percent of the world population, but it consumes 75 percent of the world's prescription drugs.

He said diabetes is a classic example. If he asks a Type II diabetes patient to lose weight, in most instances, they refuse. They want the medication to control the disease, but they don't want to change their lifestyle.

"It's the same with pain. I see people who are obese, who don't exercise regularly. They're not here to talk about lifestyle; they're here to talk about a pill to take care of pain."

It's not just pain though, Nicholson said — it's every condition. Most Americans just don't want to take responsibility for their own bodies.

"My insurance is paying you (the doctor) to take care of this for me," he said is the general attitude he sees.

• Moving Forward

Both the House and Senate recently passed the Comprehensive Addiction and Recovery Act (CARA), will Nicholson said will be helpful.

CARA's highlights include efforts to expand prevention and educational efforts; to expand the availability of naloxone to law enforcement agencies and other first responders; to expand resources to identify and treat incarcerated individuals suffering from addiction disorders; to expand disposal sites for unwanted prescription medications; and to launch a medication assisted treatment and intervention demonstration program.

Additional regulations are being considered on both the national and state level.

In Pennsylvania, Nicholson said a bill before the legislature would mandate every pharmacy benefits plan to offer at least three potential abuse deterrent formulations. One clause of the bill does not allow patients to have prescriptions refilled in an emergency room because they were lost, stolen or ran out early.

"A lot of patients will shop from one ER to another to get their drugs of choice," he said. Even for patients who are not trying to manipulate the system, Nicholson said they need to be better caretakers of their medications.

Sen. Joe Manchin recently introduced legislation that would require all states that receive certain federal funding to establish a prescription drug monitoring program (PDMP). The Prescription Drug Monitoring Act also requires states to make their program data available to other states.

Nicholson agreed legislation like this is needed nationwide. Some states, like Arizona, California and Nevada, already operate PDMPs that share a common database.

He also hopes to see the federal government provide mandates for education on how to evaluate pain for medical residents, physicians and clinicians across the country.

"There is no good formal training that's consistent in medical schools across the board. From a federal standpoint, there's a lot to be done."

He said the goal should not be bringing patient pain to "zero," but rather, to adequately understand how to evaluate someone with pain.

"We've done that with diabetes and hypertension, but pain is one of the most common complaints patients perceive."

• • •

Dr. Bruce Nicholson received his medical degree from Eastern Virginia Medical School in Norfolk, Virginia. He performed his residency in anesthesiology and pain management training at the University of Virginia, Health Sciences Center in Charlottesville. Dr. Nicholson is the director of Pain Specialists of Greater Lehigh Valley. He is the medical director for the Division of Pain Management, Lehigh Valley Hospital and Health Network, and is a clinical associate professor at Penn State's College of Medicine at Hershey Medical Center.

Dr. Nicholson is board certified in anesthesiology and pain management by the American Board of Anesthesiology. His memberships in professional societies include the American Society of Regional Anesthesia, the International Association for the Study of Pain, and the American Pain Society. Dr. Nicholson has authored numerous journal articles, abstracts and book chapters, and has lectured nationally and internationally on the subject of neuropathic pain.