Mandatory Pain Assessments Are Such a Pain
It feels like we are moving backwards!
In the beginning of the opioid epidemic, pain became the fifth vital sign, and we all know what happened after that.
The prescribing guidelines became more restrictive. States and national authorities implemented dose limits. The monitoring of physician prescribing practices and the shaming of physicians who prescribe more opiates than their peers is systematic now.
And yet, even though opiates have fallen out of favor and many of the non-opiate pain medications have at least come under suspicion, if not downright gotten viewed as inappropriate, we are now required by CMS to make ongoing pain assessments.
Lyrica is a controlled substance, its sister drug gabapentin has become popular with substance abusers, Cymbalta can cause mania, amitriptyline is viewed as inappropriate for the elderly because of side effects, largely anticholinergic. Cyclobenzaprine falls in the same category and requires prior authorization over age 65 with many insurance companies. NSAIDs can cause gastrointestinal hemorrhages and kidney damage and are associated with increased cardiovascular events. Tylenol had its maximum dose recommendation reduced several years ago because of concerns for liver damage, and so on…
So if we screen for pain with positive findings, there is no obvious, easy and safe intervention to offer. Considering that this is a throw-in when patients are actually being seen for something else, this is a prime example of Pandora’s box.
The common sense approach to screening is that it should be done when there is an effective intervention that can be offered. CMS did not in the past recommend screening for depression, for example, unless mental health resources were readily available. They changed their mind on that. But, where I work in Northern Maine, most therapists have a one year waiting list or worse. And the dirty little secret about antidepressant medications is that they work about 30% of the time - about the same as placebo.
We are mandated to screen for pain with no easy treatment options. The foundation for pain management is largely cognitive behavioral therapy, which is hard to come by as a modality that requires special skill on the part of the behavioral health counselor.
As far as interventional pain management, lumbar steroids etc., the outcomes data is mixed.
So here we are, beginning a routine visit with a patient who scores positive for pain and depression. Meanwhile, their blood pressure, blood sugar or whatever is out of control. The medical provider’s internal egg timer is ticking. How can we best help this patient in the limited time we have available?
Thanks a lot, Uncle Sam…
Whoever develops a decent drug without damaging side effects for the pain of arthritis and the wide variety of aches and pains that come with the aging process, or for those who suffer from chronic pain for whatever reason…will be a hero/heroine. I’m “lucky” that I don’t tolerate opioid based medication unless given strong anti-nausea medication along with it. The most I can tolerate is half a tramadol if I eat some candied ginger shortly after I take it. I tried gabapentin for what we thought was nerve pain in my legs (turned out it was referred pain from a hip gone down to bone on bone so hip replacement surgery cured that) and, to help with my restless leg syndrome, always bad at night. I tried various configurations of it but all it did was make me feel under water and to want to sleep all the time. I could barely function. I like functioning so I weaned myself off it. I still have a big bottle of 100 mg capsules and when I’ve had several poor nights of sleeping, I’ll take 2 of them to kind of knock me out. I have insomnia due to waking up with my legs kicking and it makes me get up to walk about and stand while I use my iPad (like now and twice earlier this night.) So whoever finds a good remedy for restless legs will be another person I’ll happily bow down to in thanks. And yes, I supposedly have spinal stenosis, spondylothesis and severe arthritis in my lower spine where I also have scoliosis. BUT. As long as I do my daily mile + walk with my dog each morning, and my chair yoga in the evening (YogaVista online yoga classes is a fantastic bargain at $12.99 a month), I stay limber enough and the aches and pains are tolerable and often go unnoticed until I get tired at the end of the day.
Incidentally, I still use my Swedish All Terrain Trionic Veloped when I walk my dog each day. He’s attached to by a leash so when he sees a cat or coyote, I can control him. Plus, the Veloped helps me walk faster, further and more evenly than walking on my own allows me to do since surgery. I do bless the men who developed this outdoor all terrain walking aid as do thousands of others (i belong to an online Trionic goup). We have 8 miles of interlocking paths that wend behind the homes and go out into open space in the community where I live in New Mexico. But the Veloped can take you anywhere on any terrain, in any weather. It’s city and country, going over curbs and rocky terrain with equal ease. I bought it when I couldn’t walk without serious pain in my leg. It really saved my sanity during the two years that my leg (oops, hip) was going bad. I’ll tell you this. I took way too much ibuprofen in those days. I got so that I didn’t care anymore if it ruined the linings of my stomach and heart. When you have intractable pain 24/7, it wears you out. I can see why people get addicted to anything that will take that pain away. I was planning to go out of State to get a second opinion on my back(the supposed issue), because I couldn’t see continuing on with that pain for the rest of my life. Discovering that it was my hip and having surgery, cured that pain and resolved that issue and I take the occasional aspirin or ibuprofen now.
I believe that doctors and teachers have so many restrictions and expectations put on them these days, that it’s crazy making. For all the doctors and teachers who stick with it, I applaud and thank you.