The front-and-center coverage of America’s opioid crisis is certainly affecting the two groups most involved: physicians and people in chronic pain. There are so many rules and restrictions on opioid prescribing that many physicians simply don’t bother any more, referring their chronic pain patients to pain management (PM) specialists. As well-intentioned as PM physicians may be, they prefer performing high-profit invasive techniques like nerve blocks and surgically inserting spinal infusion pumps to prescription writing.
This was actually explained to me when I was giving a poorly-attended lecture on fibromyalgia at a very large and well known PM center. “Yeah,” I was told by one of the doctors, “We keep one semi-retired doc on hand to write all the prescriptions. We prefer procedures!”
The logical consequence of primary physicians writing fewer opioid prescriptions for their chronic pain patients is that more patients will suffer unnecessary chronic pain. New surveys among both physicians and patients are revealing that as the opioid epidemic is controlled, we’re facing a new and brutal epidemic of untreated pain. A WholeHealth Chicago patient recently showed me a promotional flyer from one of Chicago’s larger physician groups in which two young physicians vowed they’d “never prescribe opioids.” I guess they’ll tell their chronic pain patients to just suck it up.
I wrote a previous Health Tip on the insanity of the government victimizing chronic pain patients. Rather than repeat myself, have a look here.
Two important reports
In this Health Tip, I want to talk about two reports that came out recently.
First, a huge study referred to during the annual meeting of the Academy of Integrative Pain Management (AIPM) seems to finally end any disagreement about whether or not acupuncture is effective for chronic pain. After reviewing more than 1000 published papers, researchers analyzed the results of 18,000 patients and concluded not only that acupuncture works, but that policymakers and insurance companies are obligated to look into ways to make acupuncture available and affordable nationally.
Even though acupuncture needles are about as fine as a human hair and most patients feel very little discomfort, some people are just needle-phobic. No problem. Most practitioners of Chinese medicine also are trained in shiatsu, best described as needle-free acupuncture in which fingertip pressure is applied to acupuncture points. Here’s an article on it.
As helpful as acupuncture might be for chronic pain, the researchers emphasize that it rarely works alone. Opioids for pain relief can likely be reduced with acupuncture, but medications must remain available without the stigma unhelpfully provided by many pharmacists, emergency rooms, and the young doctors vowing “no opioids ever.”
Other therapeutic modalities are needed, too, including chiropractic, relaxation techniques like yoga, physical therapy (especially transcutaneous electrical nerve stimulation–TENS–units for home use), occupational therapy, and counseling. When combined with some of these therapies, acupuncture–plus national access to medical marijuana—can reduce a patient’s overall opioid use.
Which brings up the second important issue: cost.
One significant reason patients end up using opioids over other modalities is price. Even without insurance, a one-month prescription for 60 time-release morphine tablets is $25 at Costco and $41 at Walgreens. For what’s called breakthrough pain (i.e., having an especially bad day and needing additional pain coverage), one month of Norco (120 tablets) is $26 at Costco and $29 at Walgreens. These are both generic versions.
Branded pain meds are outrageously overpriced. One month of Xtampza (a new form of “tamper- proof” Oxycontin) is $450, though if you have insurance the Xtampza company provides a coupon that reduces your cost to $35.
Now, if you consider that acupuncture sessions average $80 each, are recommended weekly, generally aren’t covered by insurance, and that patients in chronic pain often face cash-flow problems, you can see why patients turn to opioids. Even medical marijuana averages $100 to $200 monthly, though prices seem to be dropping as more dispensaries open.
The second report that came out of the AIPM meeting was a call to the government and insurance industry to spend less time and money policing opioid users and prescribers and more time and money on covering these alternative pain management modalities.
One year of Xtampza ER costs $5,400. One year of weekly acupuncture sessions (52 x $80) is $4,160. Cannabis is a weed, remember? It should be close to free instead of having its price controlled by venture capitalists looking to score big. It would seem like a no-brainer, but then you also have to consider the current condition of Washington, DC.
Patient drug testing
One final issue regarding opioid prescribing that’s steeped in controversy is mandatory drug testing. Some pain management physicians insist their patients undergo monthly urine tests to screen for both legal and illegal drugs. Through the worst-case-scenario prism, if the test result shows the prescribed drug is not present, then it’s assumed the patient must be selling it on the street. If a bouillabaisse of drugs is present, the patient must be a multi-drug abuser.
Doctors morally justify this micromanaging by claiming that it prevents addiction, which it most certainly does not. In actual fact, urinary drug testing represents a bountiful income stream (pun unintended) that recently came under a great deal of insurance fraud scrutiny. Still, I get calls from pharmacists refusing to fill opioids unless I document drug testing. (I advise my patient to go elsewhere for her prescriptions.) I also get regular visits from salespeople who want to set up a drug-testing cash cow at WholeHealth Chicago.
The point here is that the pain management situation is multi-faceted. If you’re in chronic pain and live in the Chicago area, I suggest you consider WholeHealth Chicago. We certainly have the very team of practitioners that the AIPM recommends using. We’re also unenthusiastic about surgical interventions for pain. Yes, they can be effective, but only as a last resort.
David Edelberg, MD