Is Managed Care Pushing Opiate Addiction?

America's new addiction, which I wrote about in June in the Huffington Post, is the epidemic of opiate pain killers, which, aptly named, last year resulted in over 16,000 overdose deaths. This is not the stereotyped drug problem that can be solved by Miami Vice style drug busts of traffickers and periodic round-up of street-addicts and pushers. In this epidemic, the traffickers are our respected pharmaceutical companies acting entirely within the law seeking only to bring legitimate pain relief to sufferers; the addicts are, for the most part, upstanding citizens seeking a medical solution to their pain, and the "pushers" are, with few exceptions, dedicated doctors attempting to alleviate the suffering of their patients. So how can the interaction of decent people, pursuing well intentioned and legitimate ends, result in a truly disastrous narcotics epidemic?

The answer, as counter-intuitive as it may seems, is that in large part the epidemic is an unanticipated consequence of "managed care"; which swept the country in the 1980's to contain rising medical costs.
Almost every week, I have received more calls from new patients searching for a pain specialist willing to take on the prescribing of their drug. In each case the reason given for the need for a new doctor was their previous doctor's retiring or otherwise no longer being available for the task. In each case a brief interview revealed the nature of the injury or physical problem to be either minor or at best partially diagnosed. Further, there is a turn of phrase, an urgency, a worn thin quality to their stories, which informs the practiced listener that driving the call is addiction. The previous prescriber had created a demon and had withdrawn.

As I reflect on why this wave of opiate addiction is so rapidly gaining hold in America, I realize that the answer lies in the new realities of how doctors must practice to earn their livelihood. Listening to Bill Clinton, the only campaign speaker to try to get across the mechanics of Obamacare, I learned for the first time where the funding ($617 billion) for the proposed expansion of medical insurance coverage was to come from: Hospitals, private insurers and doctors.

A proposed 27% cut in Medicare payments to physicians, already so low as to drive many physicians to refuse to see Medicare patients, is part of the agreed legislation. It is not clear that private medical practice as we know it will survive at all under these cuts. In the past five years physicians have annually fought off a pending far smaller cut, as the austere economics of managed care compels them to compromise and see increasing numbers of patients each hour. This requisite for what government administrators might call “efficiency”, cuts deeply into a commodity precious to diagnosis and patient care, especially precious in pain management; adequate time for listening, for which, under managed care, there is no commensurate reimbursement. Pain has its own special, unfortunate place in this new cut-costs at all cost system. Back and neck problems, vague complaints of limb pain can be challenging at the best of times and may take long and repeated visits, interviewing and examining to fathom and correctly treat. It takes not so much diligence as time to apply skill in getting to the bottom of some of these complaints. And time is what is rationed under this new system. In this time-is-at-a-premium climate one understands how for a harried physician, prescribing a pain killer becomes an expedient substitute for a lengthy diagnostic encounter. Indeed, in the last decade, the use of opiates in general practice pain management has become increasingly the norm. The sad truth is that under economic exigency prescribing in all fields, whether it be drugs or expensive laboratory or imaging testing, is dramatically escalating; too often replacing appropriate, in-depth office encounters between physician and patient, such that a precious gem of spoken information, which might provide the key, is never heard. This pattern is only growing: Enough pain killers were prescribed in 2010 to medicate every American adult around-the-clock for a month.


If one examines the whole story of opiate use more closely, one finds that (here too) there is another hidden and costly outcome: these prescription drugs can readily reach those for whom they were never intended. A bottle of half finished opiates lying somewhere at home can tempt a teenager, and these drugs have the power to addict within three days of use. Further, less well intentioned callers at doctors' offices have learned to mimic pain, to see multiple doctors with the same story, and then sell the prescribed drugs for handsome profits.

Looking ahead one sees that in a system where symptoms are treated, but the source of pain remains, a growing number of patients will become chronic pain sufferers. And as long as managed care continues to manifest as "efficiencies" in medical practices; doctors’ remuneration for office visits progressively is whittled down, and opiate-based pills become faster acting and more powerful, the inevitable outcome tragically is even greater opiate addiction in America.

The Doctors' Dilemma

   Last week I wrote about an epidemic of opiate pain killer addiction, and the nearly 40,000 accidental overdose deaths this led to last year. Two glaring concerns follow from this statistic. When a physician raises his pen to prescribe one of this class of drugs - be it oxycodone, vicodin, morphjine, or percocett - there is no way he or she can know ahead whether the person on the other side of the desk will become another of this growing number of addicts, a transformation that can happen in as few as three days of first use. Unwittingly the physician may be writing a death warrant. Investigators at Stanford University School of Medicine led by Dr. Martin Angst find that whether we will get addicted to opiate drugs, what dose we need for adequate pain relief and what kind of side effects we experience, be euphoria, nausea, sleepiness, dizziness, blurry thinking or none at all, is wired into our genes. While the idea of being able to test for these factors before prescribing is attractive; the worrying detail here is that the patient who has both high propensity for addiction and high dosage requirements for pain relief, and little to no unpleasant side effects, probably should not given an opiate unless already dying with a painful disease .

The truism that 80 percent of all American adults will have back pain at some time in life is born out in my office, where I treat a variety of pain sources, often from sports injuries, but equally from back or neck injuries. A number of doctors like myself in the past year or so have seen a sharp uptick in patients searching for a new doctor because the previous one no longer wants to fill the demand for opiate prescriptions. I have come to recognize the telephone call. The patient has been given opiates in one form or another for sometimes longer than ten years.  The original pain is now hard to identify and the old doctor now either feels inadequate to manage addiction or fears being cited for wrongful prescription writing. These patients fall at one or the other end of the spectrum: They have learned to mimic pain, know all the right answers to the doctor's questions and even stand and sit as though in pain, but have a normal examination; or they have come to believe there is something wrong with their nerves or skeleton that cannot be restored to pain-free normal and are resigned to a life of opiate dependence. Some in each group will already be addicted. Members of the first group I see for only as long as it takes to see their game; the opiates obtained from the doctor will be consumed by the patient or sold on the street. The second group gets my attention. Why have they fallen into this opium trap?

The sorry answer lies somewhere between the practice of medicine and its regulators; the insurance groups. Increasingly in response to steep reductions in insurance payments (known politely as "benefits") doctors are being forced either to increase volume, which is to say curtail time with each patient, or in many cases, go out of practice. Opening an envelope containing less than sixty dollars for a hour with a patient in pain can be unnerving! When I spoke with the medical director for one insurance provider about this problem he said, "you live in an antiquated world, Dr. Duncan. We pay for 15 minute office visits; patients no longer require an hour." I wonder whether he has read of Columbia University's new department, Narrative Medicine, led by Dr. Rita Charon, who like myself, has discovered that if we do not listen we cannot learn what is wrong with our patients, nor can the patients feel that we care; an important ingredient in being willing to put down opiates and do what it takes to get well.









                                                                                      

The New Drugging of America

The CDC reports that the relatively recent epidemic of opium-addiction is now America’s fastest growing drug problem. The source of most of these opiates is not the foreign cartels, traffickers, and drug dealers depicted in Hollywood movies, it is pharmacies filling prescriptions written by often well-meaning doctors for Vicodin, Oxycontin, Oxycodone, and other opoid pain relievers. According to the CDC, enough  opiates were prescribed last year to medicate every American adult with a dose of 5 mg of hydrocodone (Vicodin and others), taken every 4 hours, for a month, and have led to over 40,000 drug overdose deaths. Today there are more overdose deaths involving opoid analgesics than heroin and cocaine combined, and the public consumption of them costs health insurers approximately $72.5 billion annually. The urgent problem is the addiction of a vast number of patients whose pain but not its underlying cause is managed. While the consequences of this prescription-driven epidemic may be largely invisible to the general public, it is all too clear to doctors like myself who specialize in sports medicine, physiatry, and the treatment of a range of painful conditions.

Just recently a 71 year old patient saw me for a painful swollen knee. One year previously she had undergone total knee replacement and after the post surgical discomfort had subsided, the knee pain began. She explained that her surgeon prescribed she continue her physical therapy, but the pain worsened. She went back to her surgeon, who then prescribed Oxycontin, an opiate pain reliever. When the initial dose did little to relieve the pain, she was told to increase her dose, and continued to do so over the next two months. By the time she sought my help, not only was still in pain, but she had become addicted to the medication. The problem  is that the opoid had partially masked the underlying problem. I  requested a knee MRI, which found chronic synovial inflammation of her knee, which is treatable with steroid injections. By judicially providing this treatment, the inflammation was relieved and pain was gone. But not the addiction. For that, she needed a 30 day in-patient rehabilitation to safely detoxify her and help her reform her drug habit.

I wish I could say that this case is atypical but unfortunately, it is not. Such addiction is becoming common. Part of the problem is doctors. Some busy surgeons find it more efficient to write a prescription that might work for the pain, than to spend time attempting to find its cause. Another part of the problem is patients. Many sufferers demand immediate pain relief, and, instead of fully following their doctor’s advice, increase the dosage by seeking prescriptions from multiple doctors. Part of the problem is the government’s failure to better police prescriptions. But whatever the causes of this epidemic, the results are tragic for the patients, especially since with rigorous evaluation the cause of the pain can be solved-- and without recourse to opiate drugs.

The Ecstasy (and Agony) of Sushi

      Several years ago, a young woman came to me with neck and back pain, which had not yielded to acupuncture or physical therapy. There were tight bands in her neck and upper back muscles, yet trigger point injections, which usually alleviate this source of pain, provided no lasting relief.
      Reviewing her life style, I noted that she was a self-described "sushi addict," eating it as much as five times a week. Her blood work then showed abnormally high mercury levels.  I then made calls to three other patients who had similar symptoms.  They also were frequent consumers of Sushi.  All lived in the New York area so I called  the New York City Board of Health.  An inspector  confirmed that there were unacceptably high levels of mercury in some fish, affecting sushi served in restaurants.
     Eureka, a diagnosis: mercury poisoning. Mercury is a heavy metal that is found in the earth's crust of rocks and soil. It is released into the atmosphere by burning coal, by burning and improper disposal of manufactured products containing mercury, and from personal products such as batteries. As it gets into water, bacteria can change it into a highly toxic methylmercury, which builds up in fish, shellfish and animals that eat fish. As it moves up the food chain, with larger fish eating smaller ones, mercury can become highly concentrated. Sushi from fish at the top of the food chain, such as Tuna, Salmon, and Tile fish, can cause problems associated with mercury poisoning, which is often overlooked as it takes a while to manifest. Absorbed through the gut, methylmercury can alter critical enzyme function and affect muscles function and nerve cells in the brain and spinal cord. The result can be a gait disorder, back and neck pain, and mental-psychological problems.
     Once diagnosed, the solution was straightforward. My patients modified their sushi intake, and restricted their choices to sushi at the low end of the feed chain, such as squid, shrimp, and abalone. All the symptoms of tightness and pain subsided.
    While mercury poisoning is relatively rare in my practice, finding the source of pain often requires detailed review of a patient’s life: sleep, work ergonomics, exercise and diet. After all, when it comes to pain, we often suffer the unanticipated consequences of our life-style .

The Advantages of Ultra Sound

An ultrasound image can evaluate the nature and severity of an injury
to soft tissues, such as tendons and muscles, and thus determine the
next step in treatment without having to leave the office, or
recourse to costly MRI or CT imaging which, like X-ray,
exposes the patient to radiation. Ultrasound can "see" a foreign body,
such as a splinter, and can also see a needle, and so is used in
guiding injections, such as steroid, into tendon sheaths to reduce
inflammation in tendinitis, and joint spaces for treatment of
arthritis pain. Without imaging the needle may miss its intended
placement. Ultrasound can also detect change in blood flow, clot
formation or narrowing in arteries of the limbs and neck. For both patient and doctor, it is a great advance in sports medicine.
　
　

Botox and Rehabilitation Medicine

Botulinum toxin A, or Botox as it is commonly called, is used in
medicine to block unwanted, awkward and painful muscle contraction,
such as in childhood spasticity, wry neck or eye lid twitching. In
1989 it was FDA approved for medical purposes, and its early use
was in children with a "wandering" eye strabismus, where one eye
does not look at the object being viewed. The botox molecule
interferes with muscle receiving nerve signals to contract. The
muscle paralyzing feature of Botox , when used beneficially, has
proven to be useful in more than 50 pathological conditions, and in
2002 received FDA approval for cosmetic use.
The injection technique guides a slender needle toward the belly of
the muscle where nerve endings are known to enter. The more botox
molecules deposited the more effective the block. Its therapeutic
qualities led to its being used for muscle problems seen in later
life, such as spasticity after stroke; and its therapeutic benefits
were expanded to relieve neck and back spasm, headaches due to
muscle tension, and to control spasticity following spinal cord and
brain injuries. The doctor, who trains in Physical Medicine and
Rehabilitation to become a Physiatrist, Pain or Sports Medicine
specialist encounters these injuries frequently and is in the front
line helping the person to manage pain and recover function. The
Rehabilitation physician is first and foremost trained in the
anatomy of the body in motion -- a functioning, moving entity,
which means muscles and nerves as well as joints, tendons and
ligaments. And Botox is an essential tool she learns to handle. To
skillfully identify the problem muscle and direct the needle to the
optimal site are essential skills and take time to develop.
Successful practice of Rehabilitation also requires the ability to
understand the person with the problem; ability to listen and to
assess that person's wishes, and potential to meet them. In
Rehabilitation one frequently must make aesthetic recommendations
for a patient, for example whether a surgical procedure is needed,
not only for pain relief, but also, as in rheumatoid hand deformity
or a bent arthritic knee, for cosmetic reasons. It is a natural
and a short step to offer this capability to patients concerned by
their facial appearance. A detailed interview to understand the
person's wishes and a careful examination of the facial bone and
soft tissue structure leads to a treatment plan. Injected into
certain small muscles of the face Botox can soften, even remove
unwanted deepened expression lines. This particular therapeutic
application, is now commonly called aesthetic Botox. Practitioners
of this often do not have background in its medical therapeutic
uses, and have trained recently and exclusively in its aesthetic
use. By contrast, the pain management and sports medicine and
rehabilitation medicine physician has familiarity with the placement
of needles for all parts of the body, and known dexterity. In my
case, I have more than twenty years experience with muscle, joint
and ligament injections. This experience, with my knowledge of
anatomy, empathy and aesthetic sense, greatly enhance my ability to
provide aesthetic Botox.
　
　
　

Ultra Sound And Sports Medicine

Ultra Sound is proving to be an incredibly effective way of diagnosing and guiding treatment of sports and dance injuries. Unlike X-rays and CT scans, it does not exposes patients to radiation and is harmless, painless, non-invasive, and relatively inexpensive.

Sports injuries are commonly caused by contusion arising from sudden or wrong movement, weight lifting, or falling on the leg, arm or some other part of the body. Extremity muscles are prone to injury because of the short tendon combined with a wide muscle body and fast contraction. The observable signs are pain, swelling , and function loss, but clinical examination, as good as it might be, does not allow complete assessment of the changes of the muscles, vessels and other soft tissues, which is why other diagnostic methods are needed;.
Here is how cutting edge Ultra Sound works. Muscle fibers are bound together with capillaries surrounded by fine connective tissue, with .muscle fascia spreading between muscle fibers, and, at the end, the muscle is transformed into a tendon. Ultra sound waves produce imagery that allows the diagnostician to visualize and differentiate with great precision these structures beneath the surface and even soft tissues. Once the problem is diagnosed, ultra sound can be used to guide injections and other treatments towards solving it.