Commentary

Chronic pain management is more than filling opioid prescriptions and extending disability claims

As a profession, orthopedic surgeons have developed good short-term acute pain management programs. However, our role must be better defined in the long-term prevention and management of chronic pain. Chronic pain management should be more than filling more opioid prescriptions and extending the patient’s disability claim. We need to consider different approaches when the musculoskeletal condition producing the original pain has not resolved.

One of the difficulties of chronic pain management is that there are no diagnostic tests to consistently differentiate “real chronic pain” from the symptoms rooted in secondary gains and emotional overlays. Scales, psychological tests, pain drawings and selective blocks can be helpful. However, orthopedic surgeons often find it challenging to differentiate patients who can be helped from those who are malingers, drug dependent or are working their disability situation.

Use and abuse of opioids

According to the Office of National Drug Control Policy, opioid painkillers continue to be the most commonly prescribed medications in the United States and are the nation’s second-leading cause of accidental death after car crashes. A recent study published in the Archives of Internal Medicine estimated that 15% to 20% of doctor visits in the United Sates involve an opioid prescription. From 2000 to 2009, prescriptions have increased almost 50% and the milligrams prescribed per person also increased by 400% from 1997 to 2007, according to the study.

Douglas W. Jackson
Douglas W. Jackson

There is a tendency for busy physicians to keep prescribing opioids in ever higher doses. It is difficult and time consuming to alter the patients’ need and demands for ongoing pain medication. All of these drugs are prescribed without any significant evidence that opioids are an effective treatment for altering chronic pain symptoms.

Orthopedic surgeons treat a small percentage of the chronic pain patients in the United States. Most of these patients are treated by non-MDs (chiropractors, podiatrists, physical therapists, massage therapists, trainers, nurse practitioners, physician assistants, etc.) and by other health care specialties. The cost for all the combined treatments, medications and associated lost wages in the United States is staggering.

Red flags

We all see red flags during a busy office session. For example, suspicions are increased if, after an evaluation and while you are making your recommendations, the patient asks “which specific pain medication are you prescribing?” You make a suggestion for what you believe is most appropriate, and it is acceptable most of the time. Occasionally, the patient will say something like, “Nothing works for me except Percocet or Oxycontin” or “My body finds the other pain medications are like water.”

While you are processing this response, the patient may also request a specific sleeping medication saying the pain prevents sound sleep. Such patients stick to their requests and argue that nothing else works for them. At some point during these conversations, patients may also ask you to substantiate their disability claims and even ask if you will talk with their lawyers.

Patients with chronic refractory pain usually have one or more of the following characteristics in common: they have complaints of more than one joint or specific area of pain; they have been out of work because of pain for more than 6 months; they do not fill out a anatomic pain drawing; they often have a lawyer representing them; and they are resistant to programs to reduce their pain medications.

Variations in physician approaches

Most orthopedic surgeons have developed their own individual approaches to the refractory chronic pain patient. However, there is a great deal of variation in our approaches. Some orthopedic surgeons do not attempt to manage chronic pain patients while others surgeons refill medications and follow their patients for years. At some point in long-term pain management, the patient should be evaluated in a multidisciplinary pain management program with ongoing medical supervision and monitoring.

Over the years, I have read very little clinical research that has assisted me as an orthopedic surgeon to successfully treat refractory chronic pain patients. My preference was to tell chronic pain patients in a very straight-forward manner if I believed I could not make a difference in their chronic pain. When I could not help them, I would refer them for another opinion. That is to say this was for the patients where I recognized the chronic pain issues. I would occasionally learn that one of my patients was also getting pain medications from more than one physician or forged my signature.

Prescription registries

I know some physicians look at every patient as a potential drug abuser. This is in part because the clever patients are quite sophisticated to cover up their addictions and resourceful to get prescriptions. We have our clinical suspicions because we have learned from experience. Some physicians go as far as having their patients take periodic urine tests or even sign treatment contracts promising to take medications only as prescribed and not seek drugs from other sources.

In California, we are fortunate to have help from prescription registries that detect patients who get similar drugs from other physicians. However, the registries suffer from compliance and funding issues and only detect a small percentage of prescription drug addicts. In 2005, Congress passed a national attempt at a similar prescription registry. President George W. Bush signed the bill; however, its implementation has been hampered by inadequate funding. Because chronic pain management is recognized as such a large-scale problem, I had to take a test on chronic pain management at the time of my relicensure in California. However, the reading materials for the exam were not that helpful as they covered a fair amount of end of life pain medication issues.

Pain management centers

In my experience, it has been disappointing that many of my patients referred for chronic pain problems did not become more functional or ever return to work. Many insurance carriers do not cover addiction treatment programs. Or if they do, it is only for a short period of time and often involve a re-evaluation process. However, there is hope as pain management centers are evolving the process to include a multidisciplinary health care team approach. Even with the pain management centers’ focused approach to treating addictions, not every patient is successfully treated. Some patients become dependent on methadone or simply continue to be disabled from pain.

Needless to say, preventing the scenarios which may lead patients to becoming chronic pain management challenges is ideal. But it is a delicate balance. On one hand, we have to practice “tough love,” but at the same time, we cannot make patients feel as if we are telling them there is nothing wrong from a medical standpoint and that their problems are mental. As orthopedic surgeons, we would benefit from ongoing education and alternative approaches to refractory pain related to the musculoskeletal system. Chronic pain management needs to be more than simply filling opioid prescriptions and extending disability claims.

Reference:
  • Becker WC, Tobin DG, Fiellin DA. Nonmedical use of opioid analgesics obtained directly from physicians: prevalence and correlates. Arch Intern Med. 2011;171(11):1034-1036.
  • Douglas W. Jackson, MD, is Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Road, Thorofare, NJ 08086; email: OT@slackinc.com.

As a profession, orthopedic surgeons have developed good short-term acute pain management programs. However, our role must be better defined in the long-term prevention and management of chronic pain. Chronic pain management should be more than filling more opioid prescriptions and extending the patient’s disability claim. We need to consider different approaches when the musculoskeletal condition producing the original pain has not resolved.

One of the difficulties of chronic pain management is that there are no diagnostic tests to consistently differentiate “real chronic pain” from the symptoms rooted in secondary gains and emotional overlays. Scales, psychological tests, pain drawings and selective blocks can be helpful. However, orthopedic surgeons often find it challenging to differentiate patients who can be helped from those who are malingers, drug dependent or are working their disability situation.

Use and abuse of opioids

According to the Office of National Drug Control Policy, opioid painkillers continue to be the most commonly prescribed medications in the United States and are the nation’s second-leading cause of accidental death after car crashes. A recent study published in the Archives of Internal Medicine estimated that 15% to 20% of doctor visits in the United Sates involve an opioid prescription. From 2000 to 2009, prescriptions have increased almost 50% and the milligrams prescribed per person also increased by 400% from 1997 to 2007, according to the study.

Douglas W. Jackson
Douglas W. Jackson

There is a tendency for busy physicians to keep prescribing opioids in ever higher doses. It is difficult and time consuming to alter the patients’ need and demands for ongoing pain medication. All of these drugs are prescribed without any significant evidence that opioids are an effective treatment for altering chronic pain symptoms.

Orthopedic surgeons treat a small percentage of the chronic pain patients in the United States. Most of these patients are treated by non-MDs (chiropractors, podiatrists, physical therapists, massage therapists, trainers, nurse practitioners, physician assistants, etc.) and by other health care specialties. The cost for all the combined treatments, medications and associated lost wages in the United States is staggering.

Red flags

We all see red flags during a busy office session. For example, suspicions are increased if, after an evaluation and while you are making your recommendations, the patient asks “which specific pain medication are you prescribing?” You make a suggestion for what you believe is most appropriate, and it is acceptable most of the time. Occasionally, the patient will say something like, “Nothing works for me except Percocet or Oxycontin” or “My body finds the other pain medications are like water.”

While you are processing this response, the patient may also request a specific sleeping medication saying the pain prevents sound sleep. Such patients stick to their requests and argue that nothing else works for them. At some point during these conversations, patients may also ask you to substantiate their disability claims and even ask if you will talk with their lawyers.

Patients with chronic refractory pain usually have one or more of the following characteristics in common: they have complaints of more than one joint or specific area of pain; they have been out of work because of pain for more than 6 months; they do not fill out a anatomic pain drawing; they often have a lawyer representing them; and they are resistant to programs to reduce their pain medications.

Variations in physician approaches

Most orthopedic surgeons have developed their own individual approaches to the refractory chronic pain patient. However, there is a great deal of variation in our approaches. Some orthopedic surgeons do not attempt to manage chronic pain patients while others surgeons refill medications and follow their patients for years. At some point in long-term pain management, the patient should be evaluated in a multidisciplinary pain management program with ongoing medical supervision and monitoring.

Over the years, I have read very little clinical research that has assisted me as an orthopedic surgeon to successfully treat refractory chronic pain patients. My preference was to tell chronic pain patients in a very straight-forward manner if I believed I could not make a difference in their chronic pain. When I could not help them, I would refer them for another opinion. That is to say this was for the patients where I recognized the chronic pain issues. I would occasionally learn that one of my patients was also getting pain medications from more than one physician or forged my signature.

Prescription registries

I know some physicians look at every patient as a potential drug abuser. This is in part because the clever patients are quite sophisticated to cover up their addictions and resourceful to get prescriptions. We have our clinical suspicions because we have learned from experience. Some physicians go as far as having their patients take periodic urine tests or even sign treatment contracts promising to take medications only as prescribed and not seek drugs from other sources.

In California, we are fortunate to have help from prescription registries that detect patients who get similar drugs from other physicians. However, the registries suffer from compliance and funding issues and only detect a small percentage of prescription drug addicts. In 2005, Congress passed a national attempt at a similar prescription registry. President George W. Bush signed the bill; however, its implementation has been hampered by inadequate funding. Because chronic pain management is recognized as such a large-scale problem, I had to take a test on chronic pain management at the time of my relicensure in California. However, the reading materials for the exam were not that helpful as they covered a fair amount of end of life pain medication issues.

Pain management centers

In my experience, it has been disappointing that many of my patients referred for chronic pain problems did not become more functional or ever return to work. Many insurance carriers do not cover addiction treatment programs. Or if they do, it is only for a short period of time and often involve a re-evaluation process. However, there is hope as pain management centers are evolving the process to include a multidisciplinary health care team approach. Even with the pain management centers’ focused approach to treating addictions, not every patient is successfully treated. Some patients become dependent on methadone or simply continue to be disabled from pain.

Needless to say, preventing the scenarios which may lead patients to becoming chronic pain management challenges is ideal. But it is a delicate balance. On one hand, we have to practice “tough love,” but at the same time, we cannot make patients feel as if we are telling them there is nothing wrong from a medical standpoint and that their problems are mental. As orthopedic surgeons, we would benefit from ongoing education and alternative approaches to refractory pain related to the musculoskeletal system. Chronic pain management needs to be more than simply filling opioid prescriptions and extending disability claims.

Reference:
  • Becker WC, Tobin DG, Fiellin DA. Nonmedical use of opioid analgesics obtained directly from physicians: prevalence and correlates. Arch Intern Med. 2011;171(11):1034-1036.
  • Douglas W. Jackson, MD, is Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Road, Thorofare, NJ 08086; email: OT@slackinc.com.