- Associated Press - Monday, August 29, 2016

FALMOUTH, Mass. (AP) - The recent sanctions against doctors and “vilification” of opiate prescribers has created a glut of pain patients seeking narcotics, and many physicians are refusing to take them.

“The doctors are in a difficult position,” said Dr. Donald A. Guadagnoli, senior vice president and chief medical officer for Cape Cod Healthcare. “Our goal is to make people feel better. We tend to trust our patients. But that trust has gotten us in trouble. So many physicians have developed a healthy hesitancy to take on new patients on narcotics.”

Dr. Brian O’Malley, chairman of the RxOpiates Working Group, made up of 25 Cape doctors, said state requirements related to opiate prescribing are time-consuming.

They include using a cumbersome prescription monitoring program, drug testing patients, and having them sign pain contracts.

“It’s burdensome,” O’Malley said. “We’re coming to understand that a lot of doctors are not prescribing them.”

Terie Michon, who suffers from chronic pain, knows this all too well. She is inviting artists to contribute to an art show next month to bring attention to the plight of pain patients who cannot get opioids from local doctors or alternative treatments covered by insurance companies.

“If you have heroin addiction, you get treated,” said Michon, of Falmouth. “But if you have chronic pain, the door is shut in your face.”

This may be a regional trend, but not something he’s seeing statewide, said Dr. James Gessner, president of the Massachusetts Medical Society. But, he added, it’s something the society has been worried about because of all the attention on opioid prescribing.

“We don’t want the chronic pain patients thrown out with the bathwater,” Gessner said.

Recently released Centers for Disease Control and Prevention guidelines recommend keeping maximum daily doses of opioids to a 90 milligram morphine equivalent for chronic pain, which equals 60 milligrams of oxycodone.

If guidelines are followed, doctors should be able to treat pain patients without fear of sanctions or the police, Gessner said.

Guadagnoli said the CDC strongly emphasizes the use of non-opioid alternatives, which in the long run are safer for both patient and doctor.

Everyone agrees chronic pain presents complex challenges with no easy answers.

Michon’s saga with pain began in 2006 with a mesh implant for bladder suspension that failed. A half-dozen operations to remove the mesh over several years set off a domino effect of other issues. The mother of three grown children was once a high-energy owner of a real estate company. But now she is on disability for fibromyalgia, osteoarthritis and post-traumatic stress disorder. She suffers from occasional severe joint pain and knee pain.

“Some days are really bad,” Michon said. “You cannot walk. You cannot move. Everything is such an effort, and that’s when pain medications have an appropriate role.”

Michon’s doctor at Emerald Physicians is kind and compassionate, for which she is truly grateful, she said. Many other doctors treated her like a drug addict, and made her feel ashamed, she said.

Yet her doctor at Emerald, whom she declined to name, won’t give her opioids, such as oxycodone, to treat her occasional pain on the bad days, she said.

In fact, she said, she has been unable to find any doctor on the Cape who will. Staff at the Cape Cod Hospital Pain Center on North Street in Hyannis told her they are not taking on any new patients who need opioids, she said.

The pain center is not prescribing opioids to new patients, though they are continuing to treat existing patients who are on opioids for appropriate pain management, Dr. Guadagnoli said.

Guadagnoli said the scrutiny and “vilification” of doctors prescribing opiates has had a “chilling effect.”

Doctors who are part of Cape Cod Healthcare, which owns both Cape hospitals, the Cape Cod Hospital Pain Center, Emerald Physicians and other clinics, are still independent practitioners. There is no companywide policy on prescribing that doctors must follow, he said.

But it’s pretty clear that doctors are reluctant to see new patients wanting narcotics, Guadagnoli said.

Within the last year and a half, at least two Hyannis-based doctors have stopped practicing after being sanctioned for inappropriate opioid prescribing. Dr. Mohammad Nassery, who practiced at Ariana Pediatric Neurology, was indicted in May 2015 for illegal opioid prescribing. Dr. Conrad Benoit’s license to practice medicine remains temporarily suspended since May over allegations he overprescribed opioids.

Consequently, many chronic pain patients on opioids are seeking new doctors, Guadagnoli said. They are a labor-intensive group, since they must be seen monthly and work on alternative therapies, he said.

For years, the rates of opiate prescriptions and fatal overdoses climbed annually and doctors were blamed for causing a historic drug epidemic. Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled, according to the CDC.

Yet there has not been an overall change in the amount of pain that Americans report, the CDC stated. During the same time period, deaths from prescription opioids- drugs like oxycodone, hydrocodone, and methadone -have also quadrupled.

In the last two years, the rates of prescribing have been going down in Massachusetts.

According to the state’s prescription monitoring program, which tracks patients, doctors and pharmacies, the number of people prescribed opioids went from 391,762 in the second quarter of 2015, to 329,707 during the same period this year.

On the Cape, opioid patients went from 15,606 in the second quarter of 2015 to 13,045 during that same time period in 2016.

“It’s a tough subject, honestly,” said Dr. Anna Hallemeier of Cotuit, who recently stopped practicing primary care but worked at Emerald Physicians and elsewhere on the Cape for nine years.

Opiates “are such a double-edged sword,” she said. “They work in the short term, but with long-term chronic pain, there is not much evidence that they do anyone any favors.”

Dependence, addiction and tolerance to the medicines making the patient require higher doses over time is problematic, she said.

“The more you practice, the more you see, they are really not helpful,” Hallemeier said.

But there is a long list of alternatives therapies that work as well, or better for long-term pain management, she said. The trouble is insurance companies don’t cover many of them, or they have high co-pays, Hallemeier said.

Topical non-narcotic pain medications include a lidocaine patch or topical diclofenac gel. But getting these approved by insurance is a process.

“The amount of work we go through to get a lidocaine patch for a patient is absurd,” she said.

On this point, Michon agrees with Hallemeier.

Michon see a chiropractor and he helps a lot, she said. She is a Reiki master, and takes non-opioid medicines.

But like many people with chronic pain, Michon is on disability, and these treatments are costly.

Blue Cross Blue Shield Massachusetts, the commercial company that insures more people than any other in the state, does cover diclofenac, with a small co-pay, said Tony Dodek, assistant chief medical officer for Blue Cross Blue Shield Massachusetts. It also covers the lidocaine gel, but not the patch, he added. Chiropractic treatments must be covered according to state law, he said.

Other compounds and treatments are not FDA approved so the insurance company doesn’t cover them. Some other medicines used for pain, such as Lyrica, have no generic version and are costly, he said.

The last time Michon found a doctor who gave her opiates, she had to sign a pain management contract that required drug tests. When she tested negative for having opioids in her system, they cut her off because they said that implied she may have been selling the pills, she said.

“But I don’t need them every day, so I don’t take them every day,” Michon said. “I’m tired of being treated like a drug addict.”

In the late 1990s, doctors were told to treat pain aggressively and use opioids, Guadagnoli said.

“Now the pendulum has probably swung too far in the opposite direction,” he said.

The art exhibit will be up for the month of September, which is Pain Awareness Month. September is also National Recovery Month.


Information from: Cape Cod (Mass.) Times, https://www.capecodtimes.com

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