LINDA HARDER | PHOTOGRAPHY TRACEY BROWN
How do you manage patients in pain without risking them becoming addicts? Maryland’s Prescription Drug Monitoring Program and these tips can help.
Opiates are powerful and useful pain relievers, but they too often are abused. More Americans have died from opiate overdoses in recent years than from heroin and cocaine overdoses combined. The CDC reports that more than half of the 41,340 drug overdose deaths in the country in 2011 were related to pharmaceuticals, and that drug overdose death rates increased 118% between 1999 and 2011. Prescription drugs are often a gateway to heroin, with some 80% of heroin addicts first addicted to a prescription drug.
Prescription Drug Monitoring Program
One way Maryland physicians can now reduce abuse is with the new Maryland’s Prescription Drug Monitoring Program (PDMP), which went live December 2013. Doris Cope, MD, a pain specialist at Kure Pain Management, is thrilled with this resource. She notes, “Physicians can go online, put in a patient’s name, and track all of the controlled substances, as well as the pharmacy at which their prescriptions were filled. Maryland was one of the last states to implement such a program, but with the state experiencing increasing death rates from overdoses, this is a highly needed tool.”
Laura Herrera, MD, MPH, deputy secretary for Public Health Services, explains why Maryland was later than many states in implementing this program. “Beginning in 2006, several legislative attempts failed. A bill authorizing PDMP was signed into law by the O’Malley administration in 2011. It took about two years to develop the PDMP system that is integrated into our state health information exchange (HIE).”
“Over 40% of the deaths from overdose in Maryland since 2007 are connected to prescription pain pills, according to the CDC,” Dr. Cope observes. “Based on the experience from other states, having the monitoring program in place should significantly reduce the number of prescriptions and ‘doctor shopping.’”
PDMP Provider Access
As of September 2014, roughly 4,500 PDMP accounts had been established by pharmacies and prescribing providers, with over 12,000 visits per week. However, the program is still far short of its goal to credential all appropriate providers.
To access the PDMP, providers must register, watch an educational video, and sign a participation agreement.
Some hospital-based providers have single sign-on to the CRISP (Chesapeake Regional Information System for our Patients) portal, in which case their EHR log-in credentials are automatically relayed to the CRISP HIE. Patient information is also relayed to prevent having to re-enter patient search criteria and to access data with a single click. Interested providers can contact email@example.com or call 1.877.95-CRISP.
While PDMP is an excellent tool for prescribing physicians, there is a lag time of up to three days from the time data is entered until it is available to other providers.
“The program is just one aspect of our overdose prevention program,” says Dr. Herrera. “The PDMP allows participating providers to know what their patients are taking and how many other providers are prescribing. Our goal is to promote balanced use of prescription data that preserves the professional practice of healthcare providers and legitimate patient access to optimal pharmaceutical-assisted care. About 100 providers are signing on each week, and anyone who has a Controlled Drug Substance (CDS) and DEA number should participate.”
If patients are abusing or diverting drugs, Dr. Herrera encourages physicians, “Bring them in to discuss what the signs of abuse are, and provide referral to treatment. Our website contains links to resources for providers and patients. If a physician is not sure what to do, we’ll be happy to advise them.”
Providers should note that law enforcement can access the PDMP only if an investigation is underway.
The Medicine Abuse Project for Teens
Another resource for Maryland providers, aimed at helping to prevent drug abuse in teens, is the Medicine Abuse Project. It includes a locator for area abuse and mental health services and a standardized Drug Abuse Screening Test (DAST) that contains a 10-item and 20-item format physicians can use in their practices.
Creating an Opioid Agreement with Patients
To help monitor opiate use and educate patients about their potential risks, doctors can ask patients to sign “pain contracts” or “opioid treatment agreements” that outline a set of conditions patients must follow to stay in the practice. The goal is to discourage opiate abuse that could include excessive medication usage or selling medications. The American Academy of Pain Medicine, the American Pain Society and the Federation of State Medical Boards all recommend the use of opioid agreements in certain circumstances.
The agreements may require patients to consent to some or all of the following:
- Submit to random blood or urine drug tests
- Fill their prescriptions at a single pharmacy
- Refuse to accept pain medication from any other doctor
- Keep the medication out of other people’s reach
- Keep the medication in a locked container
- Not request early refills
- Refuse to share their medication
Providers can also include a requirement that patients have their pills counted to make sure they’re the only ones taking them.
Avoid Narcotics Without a Specific Diagnosis
Dr. Cope acknowledges, “Primary care physicians are under a lot of pressure to see a high volume of patients, and the easiest thing to do is write a prescription for a patient. But when someone has a non-specific diagnosis, especially if they’re young, you don’t want to go down the path of prescribing narcotics. It’s important to take the time at the beginning and consider the long-term impact of opioids.”
She notes that diagnosing pain can be challenging. “An MRI is like a photo of someone in a particular position. It doesn’t show the body when it’s moving so it’s not totally diagnostic. Pain experienced due to body mechanics may not show up in an MRI. Physicians need to keep in mind what the goal is – to decrease pain and increase function. If a patient is sitting on a couch, life is not better. The treatment could be worse than the disease. You can’t cure ‘sadness’ with opiates.”
Dr. Cope continues, “Opiates are a useful tool when other options don’t work; however, you need to have a clear diagnosis first. If a patient has cancer or major back surgery, for example, they aren’t going to get better. The key is how well they function and how bad the side effects from the opiates are for that patient.”
Managing Manipulative Patients
Dr. Cope cautions physicians, “If you feel like a patient is manipulating you, they probably are. As doctors, we have to do the right thing, not the popular thing. The hardest patient is one who has been using opioids for years and still has severe pain and untoward side effects. We suddenly tell them they should consider tapering their opioids. If we had started earlier giving them healthier options such as weight-loss guidance, injections, acupuncture, or body-core strengthening exercises, it would have been far better for the patients. They do best if they feel in control of their bodies. If they are passive in managing their own health, it’s a poor prognostic sign.”
Some patients fixate on their body as a way of avoiding mental health issues. Dr. Cope explains, “They insist that they are depressed because they have pain, and blame the pain for their dysfunction. I recommend that, rather than directly confronting the patient, physicians say something like, ‘the pain is causing you stress, so you’re not able to enjoy your family. After a while, your friends and family may get tired of hearing about your pain, but a counselor can take the time to listen to you.’ “
Dr. Cope recalls that one of her most challenging patients was an anesthesiologist who had charted her pain every hour for years. “She was an example of a patient who needed to change her focus from pain to something more positive. I ask patients what they really want to be able to do again. You also have to modify some patients’ expectations. If they no longer have a 20-year-old body, they have to be realistic. We are likely not able to completely cure all of their pain or difficult life problems.”
Issues with Medical Marijuana
Medical marijuana has the potential to alleviate pain for many patients with cancer, chronic pain and nausea. One study indicated that whole-plant extract of cannabis that contained specific amounts of cannabinoids, sprayed under the tongue, relieved pain and improved sleep for patients with advanced cancer.
Yet prescribing the substance presents a number of thorny issues. A Journal of the American Medical Association article on June 18, 2014, discussed the pros and cons of the medicalization of marijuana. One drawback is that most users ingest marijuana by smoking.
“THC, which is believed to be the chief psychoactive component of marijuana, is available in pill form, but does not provide the euphoria that marijuana provides,” states Dr. Cope. “Further, marijuana is not standardized, as are all other FDA-approved drugs. Also, there are potential legal issues. There’s no defined optimal dose and we know there’s withdrawal. Furthermore, marijuana contains more than 100 active products. It likely has utility, but it’s like bootleg liquor in its variability. The concept is good, but it needs to be refined, subjected to scientific randomized prospective studies and approved by the FDA for a specific dose, application and protocol.”
In Maryland, the 2014 state legislature passed a revised marijuana bill after the prior law, which was focused on limiting distribution to teaching hospitals, failed to sign up any hospitals. The Natalie M. LaPrade Maryland Marijuana Commission was charged with filling in the details of the new law’s general framework for up to 15 approved growers, regulating distributors and creating/issuing ID cards for qualified patients. Wrestling with a number of details and facing criticism at a public hearing for their first draft, they had to delay the September 15, 2014, deadline for delivering their final draft regulations. Their goal is to provide marijuana to qualifying patients by early 2016.
Early Treatment, Newer Approaches Deter Abuse
Dr. Cope notes, “Treating pain early is one way to deter later abuse and help patients avoid the path to chronic pain. Another approach to control pain is the growing use of transdermal patches, which provide a steady dose of long-acting compounds. Tamper-proof opioids that are not crushable, agonist-antagonist medications, adjunct medicines, and implantable spinal cord stimulators and intrathecal pumps are additional alternatives.”
In July 2014, the U.S. Food and Drug Administration approved Targiniq ER, a new form of OxyContin that was designed to deter abuse by combining a long-acting form of oxycodone with naloxone. “If the pills are crushed, naloxone blocks the euphoric effects of oxycodone,” says Dr. Cope. However, some experts warned the drug could wind up with unintended consequences, as the naloxone doesn’t take effect when the pills are swallowed intact.
Ganglion Impar Nerve Blocks
A newer treatment for pelvic and perineal pain is a sympathetic nerve block to the ganglion impar (also called ganglion of Walther), a collection of nerve cells near the coccyx that relay pain signals to the brain. It can sometimes be used diagnostically to pinpoint pain in the perineal area, which can be difficult due to the variety of anatomic structures that share common nerve pathways. “For patients with a history of sexual abuse, counseling plus these injections can give them hope and keep them on a positive track,” notes Dr. Cope. “They can learn to function better in their activities of daily life.”
Relief for Fibromyalgia
Fibromyalgia is diffuse myofascial pain that leads to chronic fatigue and depression and that often shifts from place to place. Dr. Cope comments, “When they get a fibromyalgia diagnosis, about half of the patients are happy to find that they aren’t ‘crazy,’ while the other half will give up. With this disorder, stress leads to muscle tension and pain and increases insulin and body fat. The best treatment is physical exercise several times a week to get increased blood flow to the muscles, as the areas where muscles connect to bone have become ischemic. That can be combined, where appropriate, with a mild antidepressant. Increasing the heart rate increases blood flow, and exercise stimulates the brain chemistry.”
Pulsed RF for Disc Pain
Patients with disc pain may benefit from a newer approach – using pulsed radio frequency at the dorsal root ganglion, branches that carry pain signals into the spinal cord and central nervous system. Dr. Cope notes, “We have been using pulsed radiofrequency in these patients with good results. Studies in the Netherlands have demonstrated the efficacy of this approach.” Newer studies in the U.S. and Canada are underway.”
Complex Regional Pain Syndrome
Complex Regional Pain Syndrome (CRPS), formerly known as Reflexive Sympathetic Dystrophy, typically occurs after an injury or surgery to a limb. It typically is characterized by extreme pain, swelling, and/or changes in skin color and temperature. Symptoms can differ widely among patients, but most experience prolonged pain experienced as ‘pins and needles’ or a burning sensation, and light touch can be painful. The pain can spread along the extremity or even to the opposite extremity.
“Treat this condition early to avoid chronic pain,” recommends Dr. Cope. Sympathetic nerve blockage, physical therapy and adjunctive medications are the first line of treatment. In refractory cases Implantable spinal cord stimulation can help patients who don’t experience relief through more conservative measures, including pain medications and physical and psychotherapy. Interestingly, one of my patients with CRPS had a mild stroke that eliminated her pain.”
Inpatient Pain Programs
In addition to existing inpatient programs at The Johns Hopkins Blaustein Pain Treatment Center and Kennedy Krieger Institute’s Pain Rehab Program, a new inpatient pain program is now available at Father Martin’s Ashley in Havre de Grace. This non-profit inpatient treatment center provides care for drug and alcohol dependency, chronic pain and other co-occurring disorders.
When to Refer to a Specialist
Referral to a pain specialist is appropriate when:
- The pain is not improving
- Function is not increasing
- The patient is manipulative or you are concerned that they may be
- When you want to know if the patient is diverting
We can do drug screens and often determine if the patient is diverting their medications,” comments Dr. Cope. “Physicians can also refer to pain specialists just for a consult, to make sure they didn’t miss anything, if they suspect that opiates are being misused or if they just want confirmation that their opioid therapy is indeed appropriate.”
Laura Herrera, MD, is a family physician and deputy secretary for Public Health Services.
Doris K. Cope, MD, a physician at Kure Pain Management is double-boarded in Anesthesiology and Pain Medicine. She has served as an examiner in both specialties, and previously was professor and vice chair of the Department of Anesthesiology and Pain Medicine at the University of Pittsburgh Medical Center and director of the largest pain fellowship in the U.S.