Monday, March 28, 2016

The perils of being manly - The Washington Post

A few years ago, I found myself in the emergency room. I had hurt my ankle playing basketball, and the pain was unbearable. I remember sitting there, waiting for someone to see me, thinking to myself that it must be broken, or fractured, or something similarly severe.

"I'm going touch your ankle in a few places," the doctor said shortly after I was brought in. "I want you to describe the pain on a scale from 1 to 10."

He pressed down onto various parts of my foot, each one more painful than the last. And yet, the numbers I uttered barely nudged, moving up from 5 to 5.5, and then from 5.5 to 6. I never said anything higher than that.

When the X-rays were in, the doctor showed them to me and told me two things. The first was that I had fractured my ankle. The second was that there was no way the pain was less than an 8. He joked that if I had sought medical care somewhere else, somewhere less precautionary in its practices, I might have been sent away with a prescription for a mild painkiller and a bag of ice.

Machismo, the driver of so many questionable decisions made by men, is a fickle thing. Sometimes, a little bit of it — a tinge of toughness — doesn't seem to hurt. In sport, for instance. Or maybe negotiation. Other times, it turns out, it can do more harm than good. Like, say, when it comes to caring for one's health.

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Tuesday, March 22, 2016

National Pain Strategy - The Interagency Pain Research Coordinating Committee

The Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services today released a National Pain Strategy, outlining the federal government's first coordinated plan for reducing the burden of chronic pain that affects millions of Americans. Developed by a diverse team of experts from around the nation, the National Pain Strategy is a roadmap toward achieving a system of care in which all people receive appropriate, high quality and evidence-based care for pain.
"Chronic pain is a significant public health problem, affecting millions of Americans and incurring significant economic costs to our society," said Karen B. DeSalvo, M.D., M.P.H., M.Sc., HHS acting assistant secretary for health. "This report identifies the key steps we can take to improve how we prevent, assess and treat pain in this country."
In 2011, in recognition of the public health problem of pain in America, the Institute of Medicine called for a coordinated, national effort of public and private organizations to transform how the nation understands and approaches pain management and prevention. In response, HHS tasked the Interagency Pain Research Coordinating Committee (IPRCC), a group of representatives from  the Department of Defense, Department of Veterans Affairs, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Food and Drug Administration, National Institutes of Health and members of the public, including scientists and patient advocates, with developing a National Pain Strategy that recognizes access to safe and effective care for people suffering from pain as a public health priority. The final Strategy being released today makes recommendations for improving overall pain care in America in six key areas: population research; prevention and care; disparities; service delivery and payment; professional education and training; and public education and communication.
More specifically, the Strategy calls for:
  • Developing methods and metrics to monitor and improve the prevention and management of pain. 
  • Supporting the development of a system of patient-centered integrated pain management practices based on a biopsychosocial model of care that enables providers and patients to access the full spectrum of pain treatment options.
  • Taking steps to reduce barriers to pain care and improve the quality of pain care for vulnerable, stigmatized and underserved populations. 
  • Increasing public awareness of pain, increasing patient knowledge of treatment options and risks, and helping to develop a better informed health care workforce with regard to pain management. 

"Of the millions of people who suffer from chronic pain, too many find that it affects many or all aspects of their lives," said Linda Porter, Ph.D., director, NIH's Office of Pain Policy and co-chair of the IPRCC working group that helped to develop the report. "We need to ensure that people with pain get appropriate care and that means defining how we can best manage pain care in this country."
The IPRCC engaged with a broad range of experts, including pain care providers, scientists, insurers, patient advocates, accreditation boards, professional societies and government officials to develop the Strategy. Upon the release of the Strategy, the Office of the Assistant Secretary for Health, in conjunction with other HHS operating and staff divisions, will consider the recommendations included in the Strategy and develop an implementation and evaluation plan based on this process. In addition, the IPRCC is creating a research agenda to advance pain-related research in an effort to realize the goals of the Strategy.
"Pain can affect all aspects of a patient's life, so we wanted to hear from everyone," said Sean Mackey, M.D., Ph.D., chief, Division of Pain Medicine, Stanford University, and a co-chair of the IPRCC working group that helped to develop the report. "Similarly, to achieve the goals in this report, we will need everyone working together to create the cultural transformation in pain prevention, care and education that is desperately needed by the American public."
Better pain care, achieved through implementation of the National Pain Strategy, is an essential element in the Secretary's initiative to address the opioid epidemic. Access to care that appropriately assesses benefits and risks to people suffering from pain remains a priority that needs to be balanced with efforts to curb inappropriate opioid prescribing and use practices. The Strategy provides opportunities for reducing the need for and over-reliance on prescription opioid medications, including:  
  • Improving provider education on pain management practices and team-based care in which multiple treatment options are offered – moving away from an opioid-centric treatment paradigm.
  • Improving patient self-management strategies, as well as patient access to quality, multidisciplinary care that does not depend solely on prescription medications, especially for vulnerable populations.
  • Encouraging the evaluation of risks and benefits of current pain treatment regimens.
  • Providing patients with educational tools to encourage safer use of prescription opioids.  
  • Conducting research to identify how best to provide the appropriate pain treatments to individual patients based on their unique medical conditions and preferences.


These efforts will build on the current work underway at HHS to equip providers with the tools and information they need to make informed patient-centered treatment decisions that include safer and appropriate opioid prescribing.

The goals of the National Pain Strategy can be achieved through a broad effort in which better pain care is provided, along with safer prescribing practices, such as those recommended in the recently released CDC Guideline for Prescribing Opioids for Chronic Pain.

Wednesday, March 16, 2016

NYTimes: Patients in Pain, and a Doctor Who Must Limit Drugs

Susan Kubicka-Welander, a short-order cook, went to her pain checkup appointment straight from the lunch-rush shift. "We were really busy," she told Dr. Robert L. Wergin, trying to smile through deeply etched lines of exhaustion. "Thursdays, it's Philly cheesesteaks."

Her back ached from a compression fracture; a shattered elbow was still mending; her left-hip sciatica was screaming louder than usual. She takes a lot of medication for chronic pain, but today it was just not enough.

Yet rather than increasing her dose, Dr. Wergin was tapering her down. "Susan, we've got to get you to five pills a day," he said gently.

She winced.

Such conversations are becoming routine in doctors' offices across the country. A growing number of states are enacting measures to limit prescription opioids, highly addictive medicines that alleviate severe pain but have contributed to a surging epidemic of overdoses and deaths. This week the federal government issued the first national guidelines intended to reduce use of the drugs.
In Nebraska, Medicaid patients like Ms. Kubicka-Welander, 56, may face limits this year that have been recommended by a state drug review board. "We don't know what the final numbers will be," Dr. Wergin told her, "but we have to get you ready."

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CDC warns doctors about the dangers of prescribing opioid painkillers - The Washington Post

With no end to the nation's opioid crisis in sight, the federal government on Tuesday issued final recommendations that urge doctors to use more caution and consider alternatives before they prescribe highly addictive narcotic painkillers.

This first national guidance on the subject is nonbinding, and doctors cannot be punished for failing to comply. But the head of the Centers for Disease Control and Prevention, which issued the guidelines, said the effort was critical to bringing about "a culture shift for patients and doctors."

"We are waking up as a society to the fact that these are dangerous drugs," Director Tom Frieden said in an interview. "Starting a patient on opiates is a momentous decision, and it should only be done if the patient and the doctor have a full understanding of the substantial risks involved."

After record numbers of overdose deaths from opioid painkillers and heroin, 2016 may prove to be the year that the federal government begins to forcefully address what has become a major public health crisis. In addition to the CDC, the Food and Drug Administration is reassessing its policies on opioid medications, the Senate has passed legislation that would expand drug abuse treatment and prevention, and the Drug Enforcement Administration is pushing physicians for more responsible prescribing. The departments of Veterans Affairs and Defense already have opioid policies for their patients.

"For the first time, the federal government is communicating clearly that the widespread practice of prescribing opioids for chronic pain is inappropriate, that the risks outweigh the benefits," said Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing, a nonprofit that has been urging a curb on the use of opiates.

Given the CDC's influence in the medical community, its recommendations are "a game changer," Kolodny said.

Lawmakers who have faulted past federal efforts to tackle the addiction epidemic also welcomed the announcement.

"I have pushed for the release of these guidelines because I have seen firsthand the devastating effects of prescription drug abuse on individuals, families, and communities," said Democratic Sen. Joe Manchin of West Virginia, which is one of the hardest-hit states. His statement called the guidelines "a critical part of our fight to end this epidemic."

Priscilla VanderVeer, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, said the organization has "long supported policies that will help combat this critical public health issue, while also ensuring access to these medicines for patients with legitimate medical needs." Such policies include expanded provider education and training on pain management and access to treatment options, she said.

Nearly 28,700 people died from overdoses of prescription opioids and heroin in 2014, according to the most recent data available. Since 1999, 165,000 people have fatally overdosed on prescription painkillers, the CDC said.

In just the past month, it said, 4.3 million have diverted the drugs for nonmedical uses.

"We know of no other medication routinely used for a nonfatal condition that kills patients so frequently," Frieden and Debra Houry, director of the agency's National Center for Injury Prevention and Control, wrote Tuesday in the New England Journal of Medicine.

The guidelines, which were delayed a few months by disputes with drug industry groups, are aimed predominantly at primary care physicians. These doctors prescribe many of the opioids but complain that they have insufficient training in how to do so.

Frieden agrees that many doctors need a refresher course on how to approach prescribing pain medications.

"When I went to medical school I had exactly one lecture on pain, and the lecture said if you give an opioid to a patient in pain, they will not get addicted," Frieden said. "Completely wrong, and yet a generation of doctors grew up being taught that."

The recommendations are not intended for doctors managing pain after cancer or surgery or during end-of-life care.

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CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

I’m a doctor. I worry every time I prescribe painkillers to a patient. - Vox

"Please, I need my Oxycodone!" my patient, M, pleaded with me.

My eyes met his. I observed every fleeting facial expression, hoping to gauge his intentions. The discussion about whether to continue to prescribe this medication was one I'd had too many times with too many patients over the past few months.

"My arthritis is always worst in the winter," he said, rubbing his lower back.

It was a snowy afternoon in clinic, and M and I were in the midst of a debate. Oxycodone is an opioid medication, and, like other painkillers such as Oxycontin, Percocet, and Vicodin, it carries a significant risk of abuse.

M said he needed the pills for their pain-relieving effects. He wanted a new prescription. I was disinclined. Opioids are highly addictive. They're often abused. Worst, they decrease the body's drive to breathe, making them deadly in some cases. As much as I wanted to trust M, his story didn't quite add up. Was he abusing the drug, even selling it? Given the rising toll of prescription narcotics, these questions weren't unreasonable.

In Massachusetts where I am a physician, unintentional deaths from opioid overdoses increased from 5.3 to 10.1 per 100,000 residents between 2000 and 2013. In 2014, the number jumped to 18.6 per 100,000. These numbers include overdoses from heroin, which works the same way as opioid pills. Some people who become addicted to painkillers, unable to afford more medication or secure a prescription, then turn to heroin. But as of 2015, prescription opiates on their own account for 44 deaths each day in the United States.

In 2014, then-Massachusetts Gov. Deval Patrick declared opioid abuse and overdose a public health emergency. In June 2015, a task force established to address the issue recommended a plan that would set aside nearly $28 million to tackle the epidemic from numerous angles.

Because opioid abuse and addiction is such a widespread problem, the patients who receive prescriptions for these pills are not always the people who take them. There is a large street market for opioids, and once in the possession of people who abuse them, prescription painkillers — along with anti-anxiety medications, such as benzodiazepines like Klonopin — can become even more dangerous when incorporated into potent drug cocktails (much like cocaine-and-heroin "speedballing"). These mixtures can be lethal given the unpredictability and variability in their contents

The possibility of drug abuse, overdose, and diversion is the backdrop to every conversation I have with a patient about opioids. Some cases are clear-cut. A patient in pain from terminal cancer, whose need for narcotics is obvious and whose potential for dependence is immaterial — I don't worry too much with patients like that. But in most cases the decision €"is far more fraught.

My task as a doctor is to take stock of each patient's risk for misuse of the medicines and weight it against the desire to treat his or her pain. There is an ever-present fear that, as much as I hate to believe it, a patient could be manipulating me.

I often recall the surprise, betrayal, and alarm one of my colleagues experienced when police caught her patient selling the pain pills she'd prescribed him for years. Safeguards such as Massachusetts's prescription monitoring program, €"which logs all controlled substances prescribed to a patient and tests for drugs in the urine, €"are helpful but can still be circumvented.

But my worst fear isn't the legal possibility of supplying an addict — so long as safeguards are reasonably followed, doctors are protected from their patient's criminal behavior. What I fear most is harming a patient or, worse yet, unwittingly playing a role in someone's death.

The simplest solution to avoid these risks, of course, is to not start patients on narcotics at all, instead relying on physical therapy, non-opioid pain medicines, and other adjuncts. But patients sometimes come to me already taking opioids. I inherited M from another physician who left the practice, and when he became my patient, he was already on a relatively high dose of Oxycodone.

His previous doctor started him on the painkillers after major back surgery with the goal of weaning him off them after he had recovered. But unlike other patients with clear motives — some sought a short course of painkillers for acute pain, for example, and then stopped the medicines as soon as possible — €"M's case was tricky.

I don't want to deny pain relief to patients who truly feel opioids help them. A prima facie refusal to ever prescribe opioids contradicts expert opinion; according to the American Pain society, for the right patients and under close monitoring, narcotics can indeed be an option as part of a chronic pain regimen.

But I do discuss the data behind narcotics for pain relief with my patients. A recent study showed that opioids in conjunction with the non-narcotic painkiller naproxen for acute lower back pain worked no better than taking naproxen alone.

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He couldn’t eat, drink or work. And doctors couldn’t explain his searing pain. - The Washington Post

Kim Pace was afraid he was dying. In six months he had lost more than 30 pounds because a terrible stabbing sensation on the left side of his face made eating or drinking too painful. Brushing his teeth was out of the question and even the slightest touch triggered waves of agony and a shocklike pain he imagined was comparable to electrocution. Painkillers, even morphine, brought little relief.

Unable to work and on medical leave from his job as a financial consultant for a bank, Pace, then 59, had spent the first half of 2012 bouncing among specialists in his home state of Pennsylvania, searching for help from doctors who disagreed about the nature of his illness. Some thought his searing pain might be the side effect of a drug he was taking. Others suspected migraines, a dental problem, mental illness, or an attempt to obtain painkillers.

Even after a junior doctor made what turned out to be the correct diagnosis, there was disagreement among specialists about its accuracy or how to treat Pace. His wife, Carol, a nurse, said she suspects that the couple's persistence and propensity to ask questions led her husband to be branded "a difficult case" — the kind of patient whom some doctors avoid. And on top of that, a serious but entirely unrelated disorder further muddied the diagnostic picture.

So on July 17, 2012, when Pace told his wife he thought he was dying, she fired off an emotional plea for help to the office of a prominent specialist in Baltimore. "I looked at Kim and it hit me: He was going to die," she said. "He was losing weight and his color was ashen" and doctors were "blowing him off. I thought, 'Okay, that's it,' and the nurse in me took over."

Her missive got results. Three weeks later Pace underwent corrective surgery for an uncommon problem that causes pain so intense and debilitating it is regarded by doctors as among the worst known.

"I knew the pain was real and I felt like my life was on the line and I just had to prove it to somebody," Pace said.

Pace's symptoms began in early 2012 when he developed an intermittent burning on the left side of his face and down his esophagus. The pain was mild at first but intensified during the day. Because Pace took medication for a host of chronic conditions including Type 2 diabetes, hypothyroidism, high cholesterol and severe depression, doctors at first suspected a drug reaction; Pace had switched antidepressants a few months earlier. Another possibility was acid reflux.

By the end of March he had developed a facial twitch, and the pain was worse, especially when he chewed. "Nothing really relieved it," he said. His family physician in Wilkes-Barre had suggested going off the antidepressant, but his psychiatrist disagreed. His symptoms were not known side effects of the medication, which was working well for Pace after other antidepressants had failed. The drug "turned my life around," said Pace, who was reluctant to stop taking it.

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