The Pain Clinic: Your Money’s Worth?

Originally Posted 7/18/2013
Like most of you, I’m not thrilled with modern healthcare.  I miss how things were twenty years ago, when I had a sense of ‘having a doctor’ who actually knew me, who had my best interests in mind.  I remember my father, a defense attorney in a small town in Wisconsin, telling me about the state’s ban on advertising by lawyers – a once-debated issue that is hard to visualize in the current era.  He believed the ban was a positive thing, helping keep the legal profession honest and avoiding the appearance of impropriety.   I remember comparing the situation to medicine and thinking ‘of course the ban is a good thing; just think of what society would think about DOCTORS, if they hung billboards for their services!
Those debates must appear bizarre to young people now, who can’t drive a mile without hearing or seeing ads urging people to sue over work grievances, accidental injuries, discrimination, medication side effects, malpractice… while hospitals and doctors compete for space for their own ads for pain clinics, wellness centers, hip and knee replacements, or robotic surgery.
Billboards announce the next great thing that one hospital has that others don’t, one medical gimmick replacing another.  ‘Pain treatment’ is one of the biggest healthcare scams of the past 20 years, with ads promising treatment for chronic pain in an ‘advanced’ or ‘collaborative’ manner.   The scam is easy to see if one drops all positive assumptions about medicine—and health insurance– and observes what happens to patients who use pain clinics.  Follow two hypothetical patients, one with insurance and another with no money or insurance, with the exact same injury—let’s say back pain from lifting crates in a factory every night for several years. Their experiences will demonstrate why being insured is not always in one’s best interest.

Epidural injection
Are epidurals worth the money for chronic pain treatment?

Our uninsured man develops pain in his lower back that does not extend into his legs, without leg weakness or incontinence.  He goes to urgent care and pays cash for the visit, and tells the doctor that he can’t afford to be referred anywhere.  The doc tells him to avoid heavy lifting for a week, and when he returns to work, to lift with his legs and knees instead of bending his back.  He is told to stretch at least 30 minutes every morning and evening and to exercise each day.  Back pain usually comes from a combination of ‘pain generators’ in muscle, bones, tendons, ligaments, and nerves in the lower back.   But the body has amazing recuperative powers, and if our hypothetical patient stretches, exercises, and avoids repeat injury, he will get better over several weeks.  Not a bad outcome for $150!
The guy with insurance goes to his doctor, who prescribes 90 tablets of Percocet and schedules an MRI.  This doctor doesn’t explain the need for stretching, assuming that the patient will hear all that from the next doc he is referring to… or maybe he recommends stretching and exercise, but the Percocet helps the patient feel less restless while sitting in front of the TV, reducing the stretching or exercising that would have helped him feel better.  When the MRI shows ‘degenerative disk disease’ (as it always does in people over 40), the doc refers him to a neurologist for EMGs.  The patient meanwhile sees his chiropractor for 5 ‘adjustments’ per week.  The neurologist refers him to a physical medicine and rehab doc, who orders physical therapy.  All of these steps in the process extract their pound of flesh, paid by either the patient or society (through higher insurance rates).
The people who are getting rich in medicine know that it’s all about PROCEDURES.   Our insured patient already paid over $1000 for his share of the costs for a lumbar spine MRI (not to mention the plain films and a CT scan done first, just in case they might be helpful).  He or his insurer paid another grand for the EMG.  The chiropractor cost another 1-4 grand, depending on the patient’s zip code.
The money really starts to flow when the rehab doc sends him to a pain clinic.  The pain clinic starts with more x-rays, CT, and MRIs, claiming that THEIR techniques will give a better look at things that the others may have missed.   For the most common diagnoses—degenerative disc disease, lumbar strain, or facet arthropathy– treatment choices include lumbar epidural steroid injections, selective nerve root injections, and local anesthetic ‘trigger point’ injections to relax tightened muscles.  The doctor’s charge to do an epidural or nerve root injection?  About $500-$1200, for a procedure that takes about 15 minutes.  An efficient doc could easily do 10-12 injections per day.  If the doc attended one of those meetings that teach ‘maximizing reimbursement’—meetings often held on cruises or tropical islands—the doc calls his office an ‘ambulatory care center’ so that he can bill ‘facility fees’, turning a $700 epidural into a $5000 ‘short stay.’
I hear what you’re thinking—that relief from back pain is WORTH the $5,000-$10,000 cost for this patient.  What if the procedure provides only partial relief—the typical result?  Or What if the epidural steroid injection only MIGHT provide pain relief— but probably WON’T?  Is it still worth as much?  What if the pain relief won’t start for a few weeks and only lasts a month or two, and then the shot must be repeated?  What if the injection can be done only 3-4 times per year, and the patient has less than a month of relief each time.  Is 3 months of moderate reduction in pain worth $15,000?
The scam is aided by a simple fact that patients often forget: most minor injuries will heal on their own without medical intervention, as long as re-injury is avoided.   It is no coincidence that many medical procedures or treatments take ‘a few weeks’ to work, the amount of time most often associated with natural healing.  You’ve heard the joke….  With treatment, you’ll improve in 14 days; otherwise a couple weeks!  Present-day back injuries last about as long as they did 50 years ago—even though we now spend tens of thousands of dollars per injury, rather than a few weeks of ‘taking it easy.’
I’m taking care to present examples that give medicine the benefit of the doubt.  I’m not mentioning the many injections done on people despite clear evidence, on exam or MRI, that the injection will do nothing for their pain.  I’m not talking about trigger injections (done thousands of times each day throughout the US) that hurt like blazes during the shot, giving the illusion of pain relief (and nothing else) when the needle is removed.  I’m not talking about the many MRI’s, ultrasounds, CTs, and EMGs that could be replaced by a smart doctor with basic physical examination skills.
And I’m not talking (until now) about the people who suffer from iatrogenic addiction—- those who go to pain clinics for aches and pains that will either gradually go away or won’t ever go away, that in either case have a trajectory of recovery that can’t be altered by the pain clinic.  The patients are prescribed opioids, and asked to return for one procedure after another.  The patients notice that the procedures are doing nothing for the pain, but they return over and over for refills on the pain pills that they now physically depend on.
The insurer eventually balks at paying for more procedures… and at this same point the pain clinic docs decide that further attempts at pain relief would be pointless.  The doc tells the patient that since he is doing nothing but prescribing pain pills, the patient should go back to his primary care doctor and never return to the pain clinic (unless a new, reimbursable injury comes along).  The referring doctor is not comfortable prescribing the same large dose of narcotics, and tells the patient to ‘taper off the pain pills’—- something that most people just can’t do.  The patient inevitably violates the opioid treatment contract by asking for early refills, smoking marijuana, missing an appointment, running out of money to pay for visits, seeing another doctor, using the wrong pharmacy, etc…. allowing the doctor to blame the patient for breaking the rules, requiring discharge.

Inconvenient Truth

Next month I will be presenting a paper at the annual meeting of ASAM, the American Society of Addiction Medicine. The paper discusses a new method for treating chronic pain, using a combination of buprenorphine and opioid agonists. In my experience, the combination works very well, providing excellent analgesia and at the same time reducing—even eliminating– the euphoria from opioids.
Ten years ago, I would have really been onto something. Back then there were calls from all corners to improve the pain control for patients. The popular belief regarding pain control was that some unfortunate patients were being denied adequate doses of opioid medications. I remember our hospital administrators, in advance of the next JCAHO visit, worried about pain relief in patients who for one or another reason couldn’t describe or report their pain. Posters were put up in each patient room, showing simple drawings of facial expressions ranging from smiles to frowns, so that patients in pain could simply point at the face that exhibited their own level of misery.
What a difference a decade makes! Purdue Pharma, the manufacturer of Oxycontin, was fined over $600 million for claims that their medication was less addictive than other, immediate-release pain-killers. Thousands of young Americans have died from overdoses of pain medications, many that came from their parents’ medicine cabinets. Physician members of PROP, Physicians for Responsible Opioid Prescribing, have called out physicians at the University of Wisconsin School of Medicine and Public Health for having ties to Purdue while arguing against added regulations for potent narcotics.
I have tried to present both sides of the pain pill debate, without disclosing my OWN opinions on the issue—at least until today. And I must be at least somewhat ‘fair and balanced,’ because I’ve received angry messages from both sides—from people telling me I’m evil for not understanding their need for pain medications, and from people telling me I’m evil for not respecting the danger of the medications.
By the way… I have a policy of not printing messages that simply call me names, or that tell me how bad a doctor I must be for writing what I do. I love a good argument, so please feel free to comment on ANY points that I’m trying to make. But I don’t think that making efforts to lead a discussion warrants personal attacks—so please, stick to the issues!
Today, though, I would like to share a couple thoughts on the issue. The thoughts came after a discussion with one of my patients with chronic pain. I have been presenting one side, then the other side, and back again, trying to remain neutral… but from all that I’ve seen as a psychiatrist and as an anesthesiologist, some things cannot be denied.
1. Some people do have chronic pain that responds to opioids. Many doctors—including the doctors who are afraid of the DEA, or the doctors who don’t want to deal with the hard work of prescribing opioids, or the doctors who want a simple world where ‘pain pills are always bad’—don’t want to admit the truth of this statement. This is, with apologies to Al Gore, a very inconvenient truth.
I find it interesting that doctors who don’t want to prescribe pain pills act as if chronic pain does not exist– as if the suffering of people with painful disorders is less important in some way, if it lasts too long. Every prescriber is aware of the need to treat acute pain, but when it comes to chronic pain, the difficulties that arise with treatment (e.g. abuse, diversion, tolerance) lead some doctors to act as if something magical happens on the road from acute to chronic. The phenomenon is the exact opposite of the old saying, ‘to a man with a hammer, everything looks like a nail.’ In this case, ‘to doctors who don’t want to use hammers, there ARE NO NAILS.’ But in truth, there ARE nails; some patients have lots of them. And we doctors have a duty to hammer away at them… (OK, enough with the analogy already!).
2. Just because some people divert opioids does not mean that other people shouldn’t have necessary pain relief. Treating pain is about as fundamental as medicine can be. I do not understand the doctors who say ‘I do not treat pain—you’ll have to see someone else’—especially when there are no doctors available to fill that role. More and more ‘health systems’ are adopting this position, at least in my area. What gives?!
3. At the same time, there is no such thing as ‘complete pain control.’ Tolerance removes the power of narcotics, and chasing tolerance always ends badly. Patients with chronic pain must use ALL tools available, including non-narcotic techniques.
4. Being prescribed pain medications comes with certain responsibilities; the responsibility to use the medications appropriately, to communicate openly and truthfully with the prescriber, to avoid ‘doctor-shopping,’ etc. At some point, patients who refuse to honor these responsibilities will lose access to pain medications—at least to some extent. Is this humane or fair? I think so, as access to pain relief for these patients is balanced against the lives of those killed by illicit use of these medications.
I’m sure I could go on… but for now, this is enough food for thought. Besides, it’s almost time for dinner! Feel free to comment—but please, be nice!
 

Needing, Wanting, and Taking Narcotics: Do opiate addicts need more or less?

Today I received a call from a patient who has been taking Suboxone for about six months, asking for help with a pain issue.  Before getting into the specific details I’ll mention something that I have mentioned many times before; some people do very well on Suboxone maintenance for opiate dependence, and others do less well.  Some people take their daily morning dose of Suboxone and then live life almost as non-addicts, rarely even thinking about opiates as they go about the business of life.  But others will remain in an addictive relationship with opiates.  The Suboxone bails them out of jams, or even prevents the jams from happening in the first place.  They don’t spend all of their money on oxycodone or heroin, and in most cases they will manage to avoid taking opiate agonists most of the time.  But they clearly think about opiates much more than would be ideal.   They dose Suboxone more than once per day, even while admitting that they are probably only getting a ‘placebo effect’ when they take that second dose late in the day.  Some are even worse off, taking little chunks of Suboxone at times because they think it gives them a ‘lift’ of energy or mood.  This type of behavior doesn’t necessarily end in disaster (although it sometimes does), but people stuck in this pattern don’t seem to benefit near as much as do those who dose once and forget opiate for the rest of the day.
The patient who called today wanted something ‘i.e. something narcotic’ for ‘severe throat pain that felt like a hole in his throat’—or as my kids would call it, a sore throat.  He didn’t have a diagnosis, but playing the odds he probably has a virus, or perhaps strep throat.  I’ve had strep throat many times, as have most people, including all of my kids.  I’m a pretty compassionate guy as far as my kids go, and I can’t think of a single time I considered treating their sore throats with a narcotic.  I did not provide narcotic for this patient either; doing so would have been unprofessional for multiple reasons, including the fact that he first needed to know what was using the sore throat, before simply masking the pain with narcotics.  But even after a diagnosis has been made, it is not appropriate to treat a sore throat with narcotics even in a person without addiction, let alone in a person with an addiction to opiates.
I have had a number of similar cases; people on Suboxone requesting narcotics for back pain, hand pain, carpal tunnel pain, fibromyalgia, a sore tooth, a sebaceous cyst… things that ‘normal’ people would never seek narcotics for!  I usually get into a discussion, and sometimes an argument, where I try to make the point that most people go through their entire life without taking a schedule II narcotic.  If they did have a schedule II narcotic prescribed it was almost always for severe pain from kidney stones, major surgery, or perhaps from an acute spinal disc herniation; NOT for a sore throat.
There are several issues at stake here and I’ll try to avoid getting them confused with each other.  First, people with opiate dependence who take or don’t take Suboxone must remember that they cannot control their use of opiates.  In the days before Suboxone, opiate addicts were scared to death about needing to take narcotics for surgery.  I remember cases I had as an anesthesiologist where addicts made me promise to withhold narcotics even if they begged for them during the post-op period.  I usually tried to convince those people that they simply HAD to take narcotic in some cases, as there are risks associated with untreated severe pain such as pneumonia from failure to expand the lungs after gallbladder surgery or heart attack from hypertension after abdominal aneurysm surgery.  To summarize, addicts could take their fear too far and avoid narcotics that were necessary to their surgical recovery, but the bottom line was that the smart addict avoided narcotics whenever possible, and was quick to recognize and admit the thought all addicts have after stumbling on a sidewalk crack:  ‘good- maybe I’ll break my leg and need some Percocet!’
Suboxone allows some degree of carelessness because taking Suboxone prevents a free-fall into compulsive opiate use.  But I see too much complacency, and it is important for addicts to realize that not everybody on Suboxone does well.  I have seen cases where an addict on Suboxone believes he/she is safe lightening the dose of Suboxone now and then and taking a couple ‘80s’ for a weekend of pain relief, only to end up back on oxycodone ‘full-time’, no longer able to benefit from buprenorphine. Opiate addiction is a ‘crafty MF’ to borrow a phrase.  We are lucky to have a tool to help some escape the misery of addiction.  But those who take sobriety for granted and abuse the opportunity provided by Suboxone are asking for a heap of misery, and there may be no respite the next time around.
A separate issue is whether opiate addicts DESERVE pain treatment, and I don’t want to be misunderstood on this issue because of my comments above.  There are times in life where a person may need potent schedule II narcotics to treat pain, and in these situations an opiate addict is as deserving of pain relief as any other patient.  I have seen MANY times over the years where a doctor will take note of an addict’s high opiate tolerance, and instead of prescribing a higher dose of narcotic will prescribe a lower-than-normal dose or none at all!  I have heard doctors say ‘out loud’ things like ‘I’m sick of these people, and I’m not giving him anything!’  When a person with a high opiate tolerance (often because of a carelessly- prescribing physician) goes to the local pain clinic for relief of genuine pain, the pain docs will look for a lucrative injection that can be performed, and in the absence of an injection they will look at the patient with a blank expression and say ‘I’m sorry but I can’t help you—I’m not giving you anything.’  They don’t want to do the hard work, and don’t want to take on the trouble of a person who has been damaged by other narcotic prescribers.  Why bother trying to help that person when the next guy has insurance that pays $700 for the 20 minutes of time it takes to do an epidural steroid injection?  If you have a high opiate tolerance and you are refused adequate pain treatment, you have rights.  If you are in that position, send me an e-mail and I will hook you up with a group that advocates for such patients– a group with many lawyers!
I hope that you can differentiate between the two situations described above.  There will always be a gray area between the two types of situations, but the ideas behind each of the two extremes are clearly different.  Opiate addicts learn to see every pain as deserving of treatment with narcotics regardless of whether the pain is coming from a viral cold, a migraine headache, or major surgery.  Addicts who do well are those who recognize that narcotics are rarely necessary and rarely if ever taken by non-addicts.  On the other hand, in the rare cases where narcotics are clearly indicated, addicts have as much right to pain treatment as does anyone else.
JJ

Question From Anonymous

I am going to move this question to a new post so that everyone can read it:
hi,
i am in recoverery and was injured, was on percocets for about three months. i kinds detoxed with a lower dose of opiates but then took a few days worth again after a hard weekend. a few days later the wd symptoms came right back! oh, i couldn’t take it so i asked my doctor for suboxone. he knew nothing about it and wanted to give me yet more opiates. after a lot of convincing he gave me 2 mg tabs/30 days worth. I want to be done with all this stuff asap- so what’s your suggestion as to how to take this just to make it through the wd’s from the opiates? thanks!

My Answer:

This question illustrates a number of points. The first point is that opiate addiction is a life-long illness. Anonymous does not say how long he or she has been ‘in recovery’, but for the most part it does not matter; people who have been clean for years or even decades will find themselves brought instantly back to the mess they thought they left behind, after just a percocet or two. As addiction is a conditioned, or learned, process, it makes sense; If I take you back to your childhood neighborhood after twenty years away, you will likely be able to find your way around without difficulty. Unfortunately we cannot erase conditioned behavior any more than we can intentionally forget bad memories.

A second point concerns the nature of withdrawal. I am convinced that the intensity of withdrawal is more related to the intensity of prior withdrawals than to the amount of drug used. I have heard people describe very severe withdrawal after minimal relapse. There is a term in medicine– ‘kindling’– which describes how CNS symptoms such as seizures become worse each time they occur. I have found that withdrawal is similar.

A third issue is the legality of prescribing opiates. It is illegal for anyone to prescribe a narcotic for the purpose of avoiding withdrawal, with the exception of certified methadone clinics or suboxone prescribers. It is illegal for a pain physician to taper a person off opiates to avoid withdrawal; it is illegal for a family practice doc to prescribe vicodin to avoid withdrawal. A family practice doc can prescribe suboxone for pain, but cannot prescribe suboxone for addiction UNLESS the doc is suboxone certified.
As for answers, My first question would be, what is/was the nature of your recovery? If you are involved in AA or NA, I recommend stopping the opiates and getting to a meeting, and then hitting as many meetings as you can for the next few months. If you hope to be opiate-free again, your best bet is to just stop using, and take the withdrawal.
If, on the other hand, your recovery was a bit ‘shaky’, or if you always had intense cravings, or if you just cannot stop using (God forbid that you have found a source of opiates), you may want to consider suboxone. Many people find that after years of being clean they still felt like an opiate addict just hanging on…. those people will often feel ‘normal’ for the first time when they take suboxone. In such a case, though, you would likely end up taking suboxone for a long time– perhaps for the rest of your life.
Suboxone can be used to taper off of opiates, but it is most useful in this regard for coming off of high doses of methadone, which is extremely difficult to do. Suboxone (buprenorphine) is a very potent opiate– much more potent than oxycodone– and so it is probably as easy or even easier to come off oxycodone than to come off suboxone. The problem is that just coming off the opiate, as tough as it seems right now, is really the easy part. The hard part is staying off of opiates, as you found after your ‘tough weekend’. If you do not have a good program going on in AA or NA, then you really may want to consider suboxone. It will prevent relapse and put your addiction into remission with a minimum of pain or discomfort. But again, this is a long term proposition– just as opiate dependence is a long term illness.