We need to speed up our acceptance of the opioid guidelines
http://www.kevinmd.com/blog/2016/12/need-speed-acceptance-opioid-guidelines.html
This was forwarded to me by a reader with the following comments on the article:
and she thinks she knows what she’s talking about. I’ve had difficulty with 2-3 NPs in the past, and didn’t really know the source of my difficulty until I asked an old friend (who’s a NP) to have dinner with me. Didn’t take me long to figure out that on issues of anxiety, pain, addiction, and behavioral medicine – he couldn’t tell his ass from his elbow. I knew more about it than he did! (the rigor of a B.S. in Mechanical Engineering, the broad liberal arts education of a Master of Divinity, a Clinical Pastoral Education residency at M.S.K.C.C. surrounded by the likes of Richard Payne and Steve Passik didn’t hurt). In the end, I was far more competent than my friend and the NPs I was having difficulty with, yet they did not recognize my competence, and in fact came to the (inevitable) conclusion that I was exhibiting aberrant drug seeking behavior.
Anyway, what the hell makes Kathryn Takayoshe, NP-C think she’s so knowledgeable and competent on these issues? Perhaps some of your blog followers may wish to comment. I think it is partly the Dunning-Kruger Effect (“a cognitive bias in which low-ability individuals suffer from illusory superiority, mistakenly assessing their ability as much higher than it really is” – https://en.wikipedia.org/wiki/Dunning%E2%80%93Kruger_effect)
A couple of years ago, I inherited a patient who was on both a patch for the powerful painkiller fentanyl and a high dose of oxycodone four times daily — and she didn’t have cancer.
I had 15 minutes with that patient to get her medical history, review her medications, assess her current complaints, and decide whether or not to continue her opioid prescriptions. I had no paper records and a very poor electronic medical record system. I lacked a lot of the information I needed in order to prescribe such a high opioid dose.
However, if I refused to continue the opioid prescriptions, I would force the patient into withdrawal. I weighed my options and came up with a reasonable plan, but it would have gone much better if I’d had some guidelines to fall back on. Amid the hubbub of the community health center where I work as a nurse practitioner, I felt stuck and alone.
We primary care practitioners want to do what’s best for our patients, including those with chronic pain, who are often some of the most challenging patients to manage. We do not want to overprescribe a potentially addictive and lethal opioid medication. In the primary care setting, all of this decision-making is happening at once, and the patient is waiting for your decision.
At the time I saw that patient on fentanyl and oxycodone, there were no formal guidelines to help me. Every provider on my team practiced differently. Some were quite liberal with their prescriptions; others rarely prescribed controlled substances. It seemed like everyone was making a personal judgment call and no one knew where to turn for proper standards of care.
These clinical decisions are not so clear-cut. For a practitioner, it is emotionally draining and time-consuming to halt opioids for a patient who has been prescribed them for years. Working in a community health center in Lynn, which, like many small New England cities, is ravaged by the opioid crisis, I have not met a single primary care provider who has decided to start opioids for a patient.
Rather, we are dealing with the “inherited” pain patient, who has been prescribed opioids by someone else. These patients usually end up with us because their previous provider left the practice, their insurance changed and they cannot see their old provider, or they burned their bridges and are looking for a new prescriber.
It’s hard to write guidelines for the management of chronic opioid therapy. The Centers for Disease Control finally came out with their first attempt in March of this year. Before that, there were a few government agencies that attempted to write guidelines on the topic, but they were weak at best, and certainly not widely followed.
Our health center decided not to wait, and has been working on our own set of guidelines for the past year. We saw the need, and we stepped in to improve our care. We created a task force that includes primary care providers, RNs, behavioral health clinicians, and an addiction specialist. We looked at existing guidelines, literature on chronic opioids and chronic pain, and expert recommendations.
The CDC guidelines are excellent, but ours go further in focusing on behavioral health and addiction treatment: We require a urine drug screen at each monthly visit. We have fully integrated behavioral health into primary care, sharing the space. Every chronic opioid patient has to get a comprehensive pain evaluation — also a step beyond the CDC. And we have our own suboxone clinic — suboxone treats opioid dependence — though we’re working to provide suboxone in primary care rather than making patients go to a separate clinic.
We are now in the process of spreading our knowledge and putting our guidelines into practice throughout the health center. So far, we have decreased the overall number of patients on risky opioid medications. More specifically, we have greatly reduced the number of those on the highest-risk medication combination: opioids and benzodiazepines. We have also increased our referrals to addiction treatment and improved our access to behavioral health treatment.
If that same patient on the fentanyl patch and opioid pills came to me today, I would be much better prepared. Perhaps more importantly, I would feel more confident and empowered. I now have standards of care and a health-center-wide task force to rely on. I would feel more supported in my decision-making. Patients need to know that they are in good hands. Our work has helped make this possible.
It has certainly been difficult. Providers are initially defensive when it comes to their prescribing practices. This is to be expected. But we need to start looking at chronic pain and opioid prescribing as we do other disease processes.
We have studies that tell us that chronic opioid therapy is not effective in improving function (and sometimes even pain) over time. We have studies that tell us that chronic opioids can cause low testosterone levels in males, chronic constipation, and even an increased pain response, among other side effects.
We have experts that tell us to prescribe only low doses of opioids and never to prescribe opioids and benzodiazepines together. We need to listen to these experts. The surgeon general recently sent individual letters to providers pleading with them to reduce their opioid prescribing.
It seems that we are always slow to adopt new guidelines. We are skeptical and resistant to change. This is one of those times when we need to speed up our acceptance. Talking about overprescribing is not enough. Primary care providers are good at following new diabetes guidelines. It’s time we do the same for chronic opioids.
Kathryn Takayoshi is a nurse practitioner. This article originally appeared in WBUR’s CommonHealth.
Filed under: General Problems
I commented on that site,,i was censored,,soo if the truth never gets out,,the truth is never told,and more people are forced to die in agony,,jmo,,there is a difference between suicide and death due to forced endurement of physical pain,and choosing death to stop the physical pain..People who commit suicide due so to stop living,,people who choose death to stop physical pain due so,,to stop their physical pain,,we don’t want to stop living,,we just want our forced physical pains to bestopped,,jmo,,and this cookie cutter sh-t will just kill more of us ,,maryw
Reading this article again I find another comment I wish to make.
In this day of what I call square centimeter medicine it’s my opinion that part of the problem is that doctors treat only their square centimeter and no one cares for the whole patient. I personally want one doctor who keeps all of my records in one place so that I can receive cohesive care. There are situations that require a specialist such as cancer but even with that one doctor needs to know ME! Once all the tests are done, the diagnosis made and a treatment plan in place I see no reason to pad the wallet of a specialist every month especially for treatment of chronic pain. If there’s a change that is the time to return to the specialist. After a period of time on pain meds, perhaps six months, to require monthly testing unless a problem appears. For someone like myself who has been on a stable and successful treatment plan of opioid pain medication for years, it makes sense to reduce appointments to once or twice a year freeing physicians who don’t have time to spend with their patients more time and give each patient appropriate care and lower the cost of treatment to a more affordable level.
Since pain treatment has become such big business I know this will never happen but it makes more sense for everyone than required monthly visits and urine tests!
THEY FORGOT , US ,, IN THE RESEARCH,,,THEE ACTUAL PATIENT,,,,m
Very well stated Lisa! I would add being forced into “behavioral therapy”. Years ago I spent a lot of time and money on a shrink for a totally different issue until I realized that especially in group therapy I felt worse every time I went! I am not an addict (and if I were I have not seen behavioral therapy to work with addicts I know) and the pain I feel is REAL so why should I take the chance of losing my second amendment rights as well as spend time and money I can’t afford on a shrink! There are no other physical ailments that I know of that have such demeaning requirements in order to receive treatment!
ditto,,,m
So your taking patients who have been on opioids & benzo’s for yrs with no problems and “saving them” by taking them off the combo? Even though if one is going to have a reaction such as respiratory depression it will be in the first several weeks statistics show? Plus these good patients your making them spend a ton of money every month for a drug screen, even if it keeps coming back normal? More trips to the Dr plus many it causes increased pain to collect a specimen, it’s not easy for everyone. You are calling tolerance ..addiction? Sending people to addiction centers placing them in MORE pain spending more of their money and putting a stigma on them (it shouldn’t but you know it will). AND YOU THINK THIS IS GOOD CARE? I would not want this treatment for anyone I love, a previous patient nor myself. This treatment IS THE PROBLEM. Dignity & Compassion…your “new program” seems to have forgotten those important qualities turning back medicine 50 yrs. More proof how bad the CDC guidelines are hurting people, not helping them. Better assessments are good, but you should have. been doing that in the first place. 15min for a initial visit is unacceptable from the beginning, it wasn’t the patient’s fault you weren’t prepared. It was yours. Former RN, CRRN.
THEY FORGOT 1 VERY IMPORTANT SOURCE OF TRUE KNOWLEDGE IN THEIR ,”RESEARCH”………..US……….!!!!!!!;;;;;;
I left the following comment at KevinMD:
With respect, I must say that the author has this story exactly wrong.
It is now very well established that the March 2016 opioid prescription guidelines are doing enormous damage to both chronic pain patients and professional pain management practitioners. Patients under-treated for pain are being deserted in tens of thousands, sometimes without even an attempt to manage withdrawal symptoms. Suicides have happened and may be increasing. Doctors are being driven out of practice by a DEA-prosecuted witch hunt justified by the so-called “epidemic” of opioid-related deaths — which in fact are only slightly related to prescription practices. Moreover, the guidelines were based on cherry-picked research and exceptionally weak medical evidence. The consultants working group ignored the detailed input of the American Academy of Pain Management (AAPM), in favor of acting in the financial interests of addiction psychiatrists — who have an abysmal record of failure in the treatment of addiction, and limited understanding or training in the treatment of chronic pain.
As only one of the many critical articles written since March has shown conclusively, the Guidelines are “Neat, Plausible, and Mostly Wrong”. The only ethically sound position in this government-sponsored mess is to outright withdraw the CDC guidelines for a major re-write by a broader stakeholder group that includes both board certified pain management specialists and chronic pain patients themselves.
“We have studies that tell us that chronic opioid therapy is not effective in improving function (and sometimes even pain) over time. and We have experts that tell us to prescribe only low doses of opioids and never to prescribe opioids and benzodiazepines together.” Well well! If those statements are true, why then once i was finally put on medications for my anxiety and also pain have I been able to purchase a home, mainly take car of it and found more success than i had in all the years I had been going to doctors! The medications were taken away and I am struggling just to keep up with house cleaning and my diagnosed anxiety attacks came back with a vengeance! Like someone else said, cookie cutter medical care! It’s shameful! We are all not the same dummies you wish we were! This is from a nurse practitioner? Oh Boy! Kathryn Takayoshi! Young lady! I was working with addicts before you were born and I am telling you right now, you don’t know shit! LOL
I get that opiods were over prescribed for some, and that many took too many, many found other doctors to get more drugs, bad outcomes were identified, and yet, many more take their prescription drugs as perscribed for real pain. I am one who has taken opiods perscribed for fibromyalgia that started about 20 years ago. It let me live better, but never addressed the fatigue and lack of sleep, nor the constant weird moving muscle pain. I tried diet changes, and thousands of dollars (which my mother gifted to me) for a special clinic in Denver which did not work. I still have pain, and all other symptoms, gone on disability and taken my prescribed pain meds as perscibed.Recently, because of the CDC’S new guidelines, I have had to gone down. And have more pain.
My husband suffered from a horrible pain disease after breaking a foot gardening. In the hospital his foot swelled, as it would, but nerve damage caused a strange disease that was called Reflex Sympathetic Dystrophy or RSD. This reaction to trauma is horrible, in that over time, the initial site of pain spreads, his first to his other foot, then up both legs. He took high levels of pain killers, but was never out of pain. Four years ago, he developed lymphoma and died.
Not because he took too many drugs. And now I believe it was a blessing, as his level of pain meds were high, and never came close to giving him relief. As horrible as it sounds if he were alive today, his doctors would be forced, by the CDC guidelines, to back off, or, as I have read about, forced him to go cold turkey, which means stop all pain meds without titration off the drugs over time.
The CDC is right in schooling pain docs about the misuse of pain meds, but take a different tact for people who have serious pain diseases. And people who can possibly take less pain meds should be helped to do so in a slow, titrated way. Cold turkey can kill, and already has.
Yes, some pain patients have turned to street drugs, heroin is one. We have, as a country, been battling the misuse of drugs for a long time. Now we have created a whole new category of drug misuse, people who were doing well with doctor prescribed drugs but have been forced to cut the amount, or go off the pain meds entirely. We will see more heroin use and suicides. They went too far, too fast. And at some point they will realize this mistake, but how many people will die, how many will have to stop working, ending up either on the streets or forced to go on disability? The new guidelines (which should not be called guidelines, these a new laws) should take a look at their negative outcomes, give pain doctors (yes I am aware of pain med mills) back their right to treat paitents. Now
They need to take those studies and put them where the sun don’t shine preferably in the most painful way possible!! A lit six inch spruce log to push it with sounds like a good way to do it!