Opioid Alternatives Webinar: Moving Away from ‘Cookie Cutter Guidelines’

05.17.2017


By Dara Barney

Out Front Ideas hosts Kimberly George of Sedgwick and Mark Walls of Safety National ran a webinar this week entitled "Alternatives to Opioids for Pain Treatment," which included Dr. Beth Darnall of Stanford University and Dr. Steve Stanos of Swedish Medical System. 

The first topic was the Center for Disease Control’s guidelines released in March 2016. Some parts of the country embraced the guidelines, but Dr. Stanos was afraid some of it was misinterpreted. He recommended evaluating benefits early on with patients so they can benefit from a pain and function standpoint. 

“Put patients on a short term trial, then stop the therapy if it doesn’t work. Some physicians think once they have a patient on a certain opioid, that they should stay on it,” he said, adding a problem with high dose opioids is that patients need to be weaned slowly, and treated empathetically or depression/anxiety could result.

“Care should be individualized, what is important is that we don’t put care in cookie cutter guidelines for pain treatment,” George said, adding that all players need to come together: The Pharmacy Benefit Management (PBMs) reps, case managers, employers and payers.

“Patients are often categorized as a morphine equivalent dose, but every patient is different. We need to reassess why they are on it, decrease the dose slowly, and look into alternatives,” Dr. Stanos said.

For an answer to, “Psychology is associated with pain, why is it underestimated?” Dr. Darnall answered: “It’s a common perception that pain is a physical experience, and by definition it’s a negative sensory and emotional experience. Psychology is built into the definition of pain. Tell patients pain is your harm alarm, pain is there to help us survive.” That is easy to do for say, when you have your hand on a hot stove, she said. But for chronic pain, the “harm alarm” doesn’t work as well. “If we don’t fully address psychology and the experience of pain, patients can think only providers can help. As a country, we need to fully orient ourselves in the realm of pain psychology.”

If psychological factors are investigated on the front end of the patient’s experience, both doctors agree it could be very beneficial, instead of sending someone to the psychologist as a last effort, or reserving it for someone with PTSD or intense depression.

In the workers’ comp space, medications, physical therapy and behavioral health visits can be time limited, so patients can benefit from concise treatment programs, according to Dr. Stanos. Overuse does exist, one example is when weekly visits turn into periodic discussions.

When asked about chiropractors, Dr. Stanos said for a patient in acute pain, it could help. Carefully screened patients that are selected for something like spinal cord stimulation can do well, but the problem of overuse can exist there as well.

And of course, a topic hot on the minds of some of the workers’ comp industry came up: Medical marijuana.

“Marijuana is still a Schedule 1 drug by the DA, and prescriptions are written under a federal license,” Dr. Stanos said. There has been some evidence that cannabinoids could be helpful with neuropathic pain, but Washington remains conservative as it is still considered a drug.

Dr. Darnall said federal laws have made it difficult to study marijuana, and the issue is people don’t know enough about it, how much to take, what to take, etc.

On the subject of “pre-habilitation,” Dr. Darnall said that setting patients up with a good exercise and nutrition program, then before a surgical setting preparing the patient for what to expect, then they can understand what they need to do to help prevent negative repercussions. 

Both doctors agreed that education plays a very important role in pain management. Dr. Darnall used the phrase “epidemic of pain being over-treated and under-treated at the same time.” 

Dr. Darnall told webinar audience members that “outcome-based focus is inevitable” with emphasis on front-end help. She said patients come to her everyday requesting alternatives to opioids.

Dr. Stanos also said the fee-for-service model will decrease, and as far as integrated behavioral health, the U.S. is in a better place than it was 5-10 years ago.


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