Rules could leave pain patients in a world of hurt
Sunday, November 6, 2011
Nadine Blair knows pain.
The 61-year-old Vancouver resident has fibromyalgia, migraines and osteoarthritis. When they all flare up, Blair is left writhing in pain.
For many years, Blair relied on medication. She had different physicians for each condition. She had various dosage levels of opioid medications for her migraines, osteoarthritis and fibromyalgia.
Yet, the pain started taking over her life.
“It was slow,” she said. “Then suddenly you wake up one morning and wonder, ‘What happened to my life?’”
Blair is one of the millions of Americans in pain.
Chronic pain affects 116 million Americans. That’s more than one-third of the population and more than heart disease, diabetes and cancer combined, according to the Institute of Medicine.
In Washington state, at least 1.7 million people, or one-quarter of the population, report issues with pain, according to the American Pain Foundation. Locally, the number of residents dealing with chronic pain could easily be in the tens of thousands.
Yet as the pain population grows, patients’ access to treatment deteriorates, said Elin Björling, Washington state policy specialist and action network manager for the Western region of the American Pain Foundation. Those with limited means have even fewer options, she said.
A survey conducted by the foundation in September revealed that 70 percent of Washington health clinics do not treat patients with chronic pain. Ten percent of community clinics treat pain patients but don’t provide opioid therapy for chronic pain.
Björling and other advocates for pain patients worry new state rules for prescribing pain medication will make finding a physician more difficult.
“We are already in a state of crisis in terms of access,” she said. “This will feed fuel to the fire.”
Last year, Washington lawmakers passed a bill to implement stricter rules for prescribing pain medication.
The rules apply only to the management of chronic pain not caused by cancer. None of the rules apply to palliative (last year of life) care, hospice or end-of-life care. They also don’t apply for management of acute pain from an injury or surgical procedure.
The new rules require patient evaluations, a written treatment plan and a written agreement for care. The rules also call on physicians to complete at least four hours of training before prescribing long-acting opioids or methadone.
One of the biggest changes — and the one raising the most concern among pain patient advocates — is the requirement for a pain specialist consultation. Prescribers with a patient who reaches an established threshold (120 mg of a morphine equivalent per day) must seek a pain specialist consultation under the new rules. Some exemptions do apply.
The rules go into effect for physicians and physician assistants on Jan. 2. For prescribers in other fields, the rules went into effect July 1.
The new rules are intended to reduce hospitalizations and deaths from opiate medications, not to improve pain care.
And that’s precisely the problem, said Jennifer Wagner, executive director of the Western Pain Society and director of clinical research at Pain Research of Oregon.
The state is facing two public health crises: prescription drug overdoses and addiction, and lack of access to pain care. The rules respond to the first crisis at the expense of the second, Wagner said.
Already some physicians have stopped accepting new patients with chronic pain and others have begun dropping pain patients.
Physicians fear the regulatory scrutiny and are confused by the new rules. Many also don’t feel knowledgeable enough to prescribe the pain medication and worry about causing addiction in patients, Wagner said.
In addition, pain patients require more time than most patients, yet the insurance reimbursement to physicians isn’t higher. Tack on the additional education and consultation requirements, and many physicians just decide against treating the patients, Björling said.
“There are some major barriers,” she said. “(The law) adds more barriers and red tape.”
Patients, no physicians
But lawmakers contend the rules aren’t to blame for physicians dropping patients.
“People are contacting my office about access problems, not about the bill, but about doctors unwilling to treat them,” said State Rep. Jim Moeller, D-Vancouver, who sponsored the legislation. “That has nothing to do with the bill at all. They’re using the bill as an excuse to get out of treating their patients, and I don’t understand why.”
Moeller, who has worked as an addiction counselor for more than 25 years, said he considers physicians who drop pain patients as failing to fulfill their Hippocratic oath.
Dr. Mimi Pattison, chair of the Medical Quality Assurance Commission, was on the committee that drafted the rules. The rules include what should be considered good practice, she said.
“If people are not going to follow the rules, which I think are a good standard of care, then I’m glad they’re not going to treat pain patients because I don’t think they’re going to do a good job,” Pattison said.
Whatever the reasons for dropping patients, Dr. Robert Djergaian is already seeing the fallout. Some local physicians have already dropped pain patients and referred them to PeaceHealth Southwest Medical Center’s new pain rehabilitation program, said Djergaian, director of physical medicine and rehabilitation at the medical center.
“I can’t help but believe that (the rules) will mean people will have less access,” he said.
In addition to primary care physicians dropping pain patients, advocates worry about the lack of specialists in the state.
Pain specialists already have big caseloads. As more and more primary care physicians stop treating chronic pain, more people will turn to pain specialists. The requirement to seek a pain specialist consultant will leave the limited number of pain specialists overwhelmed, Björling said.
“The seams are starting to tear and the capacity for everyone is at the brink of destruction,” she said.
The state committee took the shortage of pain specialists into consideration when writing the new rules, Pattison said.
The rules include a number of exemptions, she said. For example, physicians with 12 hours of continuing education in chronic noncancer pain, specifically in opioid prescribing, are exempt from the consultation, Pattison said.
The committee intentionally kept the bar high for pain specialists to prevent underqualified people from providing consultations, she said. The rules follow the American Board of Medical Specialties’ standards for pain specialists, Pattison said.
Alternatives to opiates
Another issue that has arisen from the new rules is the lack of reimbursement for alternative methods of pain management.
“Since it’s not a pain management law, it’s an opiate law, they’re hoping that patients would utilize other things in place of opiates, such as acupuncture or yoga,” Djergaian said. “The state of Washington and Labor and Industries doesn’t pay for those things.”
The state also recently limited physical therapy visits to eight per year for Medicaid patients. Most medical insurance doesn’t cover the alternative treatments but does cover opiates, Djergaian said.
The state wants to restrict opiate use but doesn’t offer tools for patients to self-manage their pain, he said.
“It requires a fair amount of work and resources to fill in the void that would be created by taking them off of opiates,” Djergaian said. “A lot of these patients don’t have the support to do that.”
The new pain rehabilitation program at PeaceHealth Southwest Medical Center aims to equip patients with those tools for self-management.
Blair, who has lived with chronic pain for several years, recently completed the medical center’s six-week program. The program consists of weekly meetings and includes physical therapists, psychologists and pain specialists.
Through the program, Blair learned relaxation techniques she uses twice a day to calm her mind and body and prevent the stress that triggered pain. She uses tricks to eliminate the negative self-talk that caused fear of pain and hampered her motivation. She has also resumed a regular exercise program, including time in the gym and the pool.
Blair is still on some medication to manage her fibromyalgia and osteoarthritis, but she’s been able to stop taking the narcotic medications. She went from having 15 migraines a month to just two. She’s planning vacations and has started ballroom dancing again.
“I think patients have to be responsible for their care, ultimately,” Blair said. “And that’s a challenge.”
For the first time, Blair said she has a comprehensive plan for her pain care.
Forming a pain society
The notion of comprehensive and collaborative pain care is spreading in Clark County.
In September, Wagner spoke to 83 local practitioners representing numerous disciplines who were interested in forming a Vancouver Pain Society. The local pain society will be modeled after the Pain Society of Oregon, which has members from multiple disciplines, including physicians, nurses, pharmacists, psychologists, chiropractors, acupuncturists, physical therapists and social workers.
The society will host monthly meetings with guest lecturers who speak on pain topics. In addition to the education, providers will have a forum to discuss pain management. Providers can network and learn from the success of others, said Shannon Wilson, who is involved in the effort and works as PeaceHealth Southwest’s spine care coordinator. Wilson is also an American Pain Foundation action network leader in Washington.
The next step, Wilson said, is to get the leadership group together and establish the society’s mission and infrastructure and plan meetings. The first meeting is scheduled for January.
The Vancouver Pain Society will be the first pain society in Washington state. So far organizers have received encouragement from local providers and political leaders who support the movement.
“I think it’s an excellent idea,” Moeller said. “It’s more than time.”
“We need to take a look at how we can best address it because it’s not going to go away,” he added. “By doctors throwing up their hands and saying, ‘I’m not going to deal with it anymore,’ that’s the wrong avenue.”