Treating Chronic Pain Just Got Harder for Primary Care Doctors (PPT) By Floyd Arthur http://carmoongroup.com

1. Treating Chronic Pain Just
Got Harder for Primary Care
Doctors
By Floyd Arthur

2. Amidst a still-swirling
controversy, the Centers for
Disease Control unveiled its
new

3. opioid guidelines last week;
as expected, they mainly
target primary care
physicians

4. treating chronic pain. The
final guidelines differ little
from the draft released last

5. December, although some
specific dose
recommendations have been
removed.

6. Probably the most
controversial of the agency’s
12 non-binding
recommendations is No.

7. 1 -- the edict that opioids
should not be first line
therapy for chronic pain.
Instead, the

8. agency recommends non-
opioid pain relievers and
nonpharmacologic therapies,
such as

9. exercise and cognitive
behavioral therapy, for the
treatment of most types of
chronic noncancer pain.

10. The guidelines were issued in
response to the nation’s
current epidemic of opioid

11. misuse, which is responsible
for about 40 deaths each day.
Calling the widespread

12. misuse “doctor-driven” CDC
director Tom M.D., MPH,
said in a news conference,
"For

13. the vast majority of patients,
the known, serious and all
too often fatal risks far
outweigh

14. the unproven and transient
benefits, and there are safer
alternatives."

15. The guidelines do not
address those “safer
alternatives” specifically, nor
do they speak to

16. the issue of insurance
reimbursement for
nonpharmacologic therapies,
a sticking point

17. brought up my many
physician groups.

18. The Complexities of Treating
Chronic Pain

19. Although the CDC
guidelines are technically
non-binding, they are certain
to have a

20. chilling effect on primary
care physicians treating
chronic pain. Legislative
mandates

21. that set arbitrary limits on the
number of pain pills doctors
can prescribe add another

22. layer of complexity in
many states.

23. Take the case of Dr. Robert L.
Wergin, chairman of the
board of the American
Academy

24. for Family Physicians and a
primary care physician in the
rural town of Milford,

25. Nebraska. Wergin is the only
doctor in the small town of
just over 2,000 residents,

26. many of whom he has
treated for dozens of years.
He does not prescribe opiates
lightly,

27. but for patients with severe,
chronic pain, he knows they
are the treatment of last
resort.

28. “I have a patient with
inoperable spinal stenosis
who needs to be able to keep
chopping

29. wood to heat his home,” said
Dr. Wergin in an interview
with the New York Times. “A

30. one-size-fits-all prescription
algorithm just doesn’t fit him.
But I have to comply.”

31. Additionally, he points out,
many of his patients lack the
wherewithal to visit pain

32. specialists in Lincoln, 30
miles away. Nor can they
afford to pay for physical or
psychological

33. therapy, which typically
carry a hefty co-payment, if
they are covered by
insurance at all.

34. And there are
contraindications to non-
opiate pain medicines,
particularly in the

35. elderly. Nonsteroidal anti-
inflammatory drugs, in
particular, are not
recommended for

36. long term use in patients
over the age of 65. Nor are
benzodiazepines, which are

37. sometimes given to provide
adjunctive relief for chronic
pain.

38. A Flawed Approach to
Treating Chronic Pain?

39. Although the American
Medical Association was
“largely supportive” of the
CDC

40. guidelines, the group took
issue with the lack of patient
input when the agency issues

41. the draft guidelines last
year.

42. Said James L. Madara, MD,
Executive Vice President and
CEO of the AMA, "The

43. guidelines and supporting
discussion are devoid of a
patient-centered view and
any real

44. acknowledgment or empathy
of the problems chronic pain
patients may face," he said.

45. Additionally, the evidence
supporting the
recommendations is “low to
very low,” said

46. Sharon Hertz, director of the
Division of Anesthesia,
Analgesia and Addiction
Products for the FDA.

47. And in a formal objection
filed with the CDC last year,
the National Institute of
Health’s

48. Interagency Pain Research
Coordinating Committee
echoed her sentiments,
calling the

49. guidelines “ridiculous” and
“an embarrassment.” The
panel consists of
representatives

50. from the FDA, the
Department of Defense, the
Agency for Healthcare
Research and

51. Quality, the Department of
Veterans Affairs and the
CDC.

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