[fmichael]

This went up a little while ago on the NY Times website:

July 28, 2010

Move to Restrict Pain Killers Puts Onus on Doctors

By BARRY MEIER

In an unusual move, a state government is developing regulations meant to stop doctors from prescribing higher doses of powerful — and often dangerous — pain killers for patients who are not benefiting from them. The effort, in Washington State, represents the most sweeping attempt yet to stem what some experts see as the excessive use of prescribed narcotics, and it is being closely watched by medical professionals elsewhere. Among other things, Washington would apparently become the first state that would require a doctor to refer patients on escalating doses of pain killers for evaluation if they were not improving.

* * *

The panel is expected to require that, among other things, doctors refer patients to a pain specialist for review when their daily medication increases to a specified dosage level and they do not show improvement. The specialist can then determine whether to continue the drug, reduce it or use other treatments like physical therapy.

* * *

“There is a dissonance in not recognizing the nexus between poor pain management and the hyperconsumption of opioids,” said Dr. Cahana, who works at the University of Washington Medical Center in Seattle, using a medical term for narcotic pain killers like OxyContin.

For his part, Dr. Franklin, whose department oversees the state’s workers’ compensation program, said he had long seen the problem play out among claimants. “Injured workers were coming into the system with low back pain and dying two or three years later” from drug overdoses, he said.

* * *

A major hurdle to making the program work is the lack of pain management specialists, particularly in rural areas of the state, where patients on the narcotics could be referred for evaluation. Dr. Franklin said the state hoped to increase the use of telephone consultations as well as help to finance the training of doctors in pain treatment.

http://www.nytimes.com/2010/07/29/bu...29pain.html?hp

Now, the issues addressed by Drs. Franklin and Cahana - standing alone – are legitimate.

First, I know all too well from the experience of a perhaps one of my closest personal friends, whose memorial service I attended yesterday, that unchecked opioid doses can magnify or even stimulate pain significantly: in her case a Dilaudid pump was once responsible for such hideous pain that it drove her to attempt to over-dose herself, only to wake up in the hospital after detoxification in significantly less pain than she had experienced in over a year. A phenomenon known as “opioid-induced hyperalgesia (OIH)”. See, e.g., Altered quantitative sensory testing outcome in subjects with opioid therapy, Chen L, Malarick C, Seefeld L, Wang S, Houghton M, Mao J, Pain 2009 May;143(1-2):65-70. Epub 2009 Feb 23 FULL TEXT @ http://www.ncbi.nlm.nih.gov/pmc/arti...nihms94277.pdf:

MGH Center for Translational Pain Research, Department of Anesthesia and Critical Care, WACC 324, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.

Abstract
Preclinical studies have suggested that opioid exposure may induce a paradoxical decrease in the nociceptive threshold, commonly referred as opioid-induced hyperalgesia (OIH). While OIH may have implications in acute and chronic pain management, its clinical features remain unclear. Using an office-based quantitative sensory testing (QST) method, we compared pain threshold, pain tolerance, and the degree of temporal summation of the second pain in response to thermal stimulation among three groups of subjects: those with neither pain nor opioid therapy (group 1), with chronic pain but without opioid therapy (group 2), and with both chronic pain and opioid therapy (group 3). We also examined the possible correlation between QST responses to thermal stimulation and opioid dose, opioid treatment duration, opioid analgesic type, pain duration, or gender in group 3 subjects. As compared with both group 1 (n=41) and group 2 (n=41) subjects, group 3 subjects (n=58) displayed a decreased heat pain threshold and exacerbated temporal summation of the second pain to thermal stimulation. In contrast, there were no differences in cold or warm sensation among three groups. Among clinical factors, daily opioid dose consistently correlated with the decreased heat pain threshold and exacerbated temporal summation of the second pain in group 3 subjects. These results indicate that decreased heat pain threshold and exacerbated temporal summation of the second pain may be characteristic QST changes in subjects with opioid therapy. The data suggest that QST may be a useful tool in the clinical assessment of OIH.

PMID: 19237249 [PubMed - indexed for MEDLINE] PMCID: PMC2680088

http://www.ncbi.nlm.nih.gov/pubmed/19237249

Only problem was, my friend's pump had been prescribed and monitored by one of the best pain specialists in a large city with a "top 5" medical school. So the requirement that meds be administered by a certified pain specialist, while no doubt a useful response ot the risk of OIH, isn’t a panacea.

As to the issue of accidental overdose, if that is backed up with epidemiological studies – as opposed to anecdotal information – that too is a legitimate concern. Nevertheless, the last sentence of the N.Y. Times article points out the crucial flaw: in any requirement that Schedule II meds be prescribed by a certified pain specialist: access to services. And while the article mentions access issues for people in rural areas, another is raised for patient with low reimbursement insurance providers, such as Medicaid. Furthermore, at least in Los Angeles I know of at least one prominent pain specialist who refuses to accept ANY insurance: it’s cash up front please, and God bless to the extent you get out-of-network reimbursement from your carrier at the end of the day.

But there is a far more insidious problem just around the corner, the next shoe waiting to fall if you will. The N.Y. Times article also includes the following:

This year, Dr. Cahana and Dr. Franklin testified during a legislative hearing on the proposed training requirement, suggesting that legislation should instead require a set of medical practices based on the best available evidence. Dr. Franklin said that a draft of rules would probably be finished by this fall and that the new regulations would be in place by next year.

As noted in the article Dr. Alex Cahana is a pain medicine specialist at the University of Washington, Seattle., where he also holds the titles of Professor of Anesthesiology and Chief, Division of Pain Medicine. http://www.medical.washington.edu/bi...ntralId=173616 Two issues are important here. First, Dr. Canana has previously written on the difficulties inherent in applying evidence-based medicine to pain management. Ethical and epistemological problems when applying evidence-based medicine to pain management, Cahana A, Pain Pract. 2005 Dec;5(4):298-302:

Abstract
Epistemology, or the theory of knowledge, is a branch in philosophy concerned with the definitions of knowledge and evidence. Although evidence-based medicine (EBM) has a strong ethical imperative behind it, rooted in the concern to do no harm, to do one's best for one's patients, and by doing so--eliminating waste, it still harbors within it serious epistemological limits. These include methodological and ethical limits to perform randomized controlled trials, the idea of "hierarchy of evidence" which may provide conclusions well short of medical knowledge, and the unique use of a single particular theory of statistical inference which is far from consensual. In this article, we review these difficulties and suggest that EBM is at best a methodological solution to some clinical phenomena, but remains blind to mechanisms of explanation and causation needed, in order to advance our knowledge. Further research in the theory of evidence and inference, causation and correlation, clinical judgment and collective knowledge, the structure of medical theory, and the nature of clinical effectiveness are needed.

PMID: 17177762 [PubMed]

http://www.ncbi.nlm.nih.gov/pubmed/17177762

Secondly, and far more important, the University of Washington has long been at the center of “cognitive behavioral” treatments from non- cancer chronic pain, eschewing the long-term use of opioids in favor of instilling a positive attitude in the mind of the patient as to how s/he can continue to be a productive member of society, not withstanding whatever levels of subjective pain the patient may be aware, if s/he chooses to acknowledge it at all. There are, for instance some 378 articles that are pulled up in PubMed under the search “Cognitive behavioral therapy University of Washington.” And the breath of the conditions covered is broad.

Unfortunately, when applied to CRPS, as wide as the brush claims to be, it is often appplied in far too short strokes: programs lasting a week or two that attempt to reprogram folks while pulling them off their meds, more or less cold turkey. For more on this in practice, check out Jennelle’s post from 08.15.09 in the update on the pain program thread http://neurotalk.psychcentral.com/sh...ad.php?t=97899 and authorities cited in my response to her (post #4).

That said, while I totally buy off on the well established principle that “catastrophizing” makes the experience of chronic pain so much worse and that everything should be gone to address it, the fastest thing I’ve seen to begin to make the kind of necesssary mental adjustments are the 8 – 10 week Mindfulness Base Stress Reduction classes, which combine a small group 2 and ˝ hour class that meets once a week, with daily yoga - great for proprioception - meditation and reading and a day-long “retreat” at the end of the class. http://www.mindfullivingprograms.com/whatMBSR.php

Jennelle’s experience (above) stands out as how badly a strick regeme of of cognitive-behavoral therapy serves a patient in severe pain. But just the idea that in a short period of time, someone can almost literally pound an entire reinterpretation of a patient’s moment by moment into his or her head, all the while the patient is in great pain and desperate for relief from suffering, is something I find cult-like and offensive. Yet here it is in black and white: Psychological pain treatment in fibromyalgia syndrome: efficacy of operant behavioural and cognitive behavioural treatments, Thieme K, Flor H, Turk DC, Arthritis Res Ther. 2006;8(4):R121, FULL TEXT @ http://arthritis-research.com/content/pdf/ar2010.pdf

Department of Clinical and Cognitive Neuroscience, University of Heidelberg, Central Institute of Mental Health, J5, 68169 Mannheim, Germany. thiemek@u.washington.edu

Abstract
The present study focused on the evaluation of the effects of operant behavioural (OBT) and cognitive behavioural (CBT) treatments for fibromyalgia syndrome (FMS). One hundred and twenty-five patients who fulfilled the American College of Rheumatology criteria for FMS were randomly assigned to OBT (n = 43), CBT (n = 42), or an attention-placebo (AP) treatment (n = 40) that consisted of discussions of FMS-related problems. Assessments of physical functioning, pain, affective distress, and cognitive and behavioural variables were performed pre-treatment and post-treatment as well as 6 and 12 months post-treatment. Patients receiving the OBT or CBT reported a significant reduction in pain intensity post-treatment (all Fs > 3.89, all Ps < 0.01). In addition, the CBT group reported statistically significant improvements in cognitive (all Fs > 7.95, all P < 0.01) and affective variables (all Fs > 2.99, all Ps < 0.02), and the OBT group demonstrated statistically significant improvements in physical functioning and behavioural variables (all Fs > 5.99, all Ps < 0.001) compared with AP. The AP group reported no significant improvement but actually deterioration in the outcome variables. The post-treatment effects for the OBT and CBT groups were maintained at both the 6- and 12-month follow-ups. These results suggest that both OBT and CBT are effective in treating patients with FMS with some differences in the outcome measures specifically targeted by the individual treatments compared with an unstructured discussion group. The AP group showed that unstructured discussion of FMS-related problems may be detrimental. [Emphasis added.]

PMID: 16859516 [PubMed - indexed for MEDLINE] PMCID: PMC1779398 Free PMC Article

http://www.ncbi.nlm.nih.gov/pubmed/16859516

But as suggested in today's N.Y. Times article, these are the same folks - along with their brethren at certain other prestigious institutions which long ago decided to keep house with the workers' comp industry - who would be only too happy to write essentially binding “best practices guides.”

Scary stuff when you think about it. Especially when you consider the depth of understanding of CRPS on which neuroscience now appears to be on the cusp, the very thought that keeping patients off pain meds could be at the top of someone's list of "best practices" is mind boggling. See, e.g., Abnormal thalamocortical activity in patients with Complex Regional Pain Syndrome (CRPS) Type I, Walton KD, Dubois M, Llinás RR, Pain 2010; In press, FULL TEXT @ http://www.rsds.org/2/library/articl..._Pain_2010.pdf

So how about focusing instead on providing early and aggressive treatment to suspected cases of RSD/CRPS? As opposed to slow, incremental, ineffectual and cheap, the way the industry appears to like it.

Mike