LAKELAND — As Tallahassee works on legislative solutions to opioid abuse and deaths, doctors and hospitals have started changing policies that try to balance pain control against the possibility of addiction.
For those who have lost loved ones, getting to this point of political action has been an arduous journey. But for patients who have severe, chronic pain relieved only by powerful drugs, and for the professionals who treat them, parts of the legislative proposals are problematic.
According to the national Centers for Disease Control and Prevention, between 1999 and 2016, more than 200,000 Americans died from overdoses related to prescription opioids. The number of deaths was five times higher in 2016 than in 1999.
In Florida’s Medical Examiner District 10 — which includes Polk, Hardee and Highlands counties — there were 190 prescription-drug related deaths in 2016 (compared with 75 illegal-drug deaths). Not all those prescription drugs were opioid based; some involved sedative-type drugs, such as Ambien, or anti-anxiety drugs, such as Xanax. But for many who abuse drugs, the addiction started with a prescription.
var divElement = document.getElementById('viz1515697557133'); var vizElement = divElement.getElementsByTagName('object')[0]; vizElement.style.minWidth='420px';vizElement.style.maxWidth='650px';vizElement.style.width='100%';vizElement.style.height='587px'; var scriptElement = document.createElement('script'); scriptElement.src = 'https://public.tableau.com/javascripts/api/viz_v1.js'; vizElement.parentNode.insertBefore(scriptElement, vizElement);
The controversy
The CDC came out with guidelines in March 2016 that address treating acute pain and chronic pain outside of cancer, palliative and end-of-life care.
Basically, alternative therapies should be tried or offered, including:
• Patient education.
• Non-opioid, non-narcotic drug options, such as non-steroidal drugs, aspirin and Tylenol.
• Non-medication options, such ice, heat, exercise and physical therapy.
When opioids are needed, the CDC recommends the lowest effective dose: For acute pain, that should be limited to a three-day prescription or, if a doctor deems it medically necessary, a seven-day prescription.
The most controversial part of the Florida bill, which is now in committee, would turn that three-day and seven-day guideline into law.
The bill would also expand measures Florida took in 2010 and 2011 to more closely regulate pain-management clinics and to set up a statewide database to help physicians and pharmacists monitor prescription usage among patients.
It is still early in the legislative session, which convened Tuesday with many bills already submitted, so there likely will be give-and-take on details or the bill may not advance.
But locally and across the state, regardless of whether the CDC guidelines are codified, health-care providers have developed and are continuing to work on protocols for treating pain and prescribing medications that can be addictive and are often abused.
Dr. Mark Vaaler, chief medical officer and vice president of physician services for Bartow Regional Medical Center and three other BayCare hospitals, said there are two separate issues involving treating pain with opioids.
“We have to find a way to separate out the patients with intractable, long-term chronic pain who cannot get by with a three-day or five-day or seven-day prescription,” Vaaler said.
“What we are trying to do with policies and task forces is prevent people from getting addicted,” Vaaler said. “And getting addicted is easy to do, some people can become addicted in several days. It is not like alcohol, which can take months, years, even decades, to get addicted.”
Yet not everyone gets addicted, and it is not clear why certain drugs are highly addictive to some people and not to others.
Pain
“Pain is a complex issue,” said Dr. Timothy Regan, president of Lakeland Regional Health Medical Center and chief medical officer for the LRH system. Regan, whose background is in emergency medicine, said some patients come out of a surgical procedure, trauma or acute illness expecting they will have pain. Others have a different reaction, demanding relief.
And people experience pain differently, Regan said.
“Some patients come in with what I would see as a minor injury and are in extreme pain, and some patients suffer devastating injuries yet require no medication,” he said.
“We want to make sure the patient is not suffering,” yet balance that out by looking for alternatives to opioids or if prescribing opioids for acute pain, limiting it to small amounts, Regan said.
Dr. Michael Schlosser, chief medical officer for HCA — the large Nashville-based private hospital chain that owns Poinciana Medical Center and nearby Osceola Regional Medical Center — recently made headlines after he told Nashville Public Radio about his company’s new protocol under which HCA doctors will tell patients they "will treat the pain, but you should expect that you're going to have some pain. And you should also understand that taking a narcotic so that you have no pain really puts you at risk of becoming addicted to that narcotic."
Regan said he would phrase it differently but “there has to be a conversation with patients. This is a partnership among the physicians, pharmacists and patients. As physicians, we are working to heal and avoid harming the patient.”
These days when patients are sent home from the emergency department, it is with only enough pain medication to last a couple of days, Regan said.
“If patients need more medication, they need to be reassessed,” whether by their primary-care doctor, an orthopedist, a neurologist or other specialist, Regan said.
“It has to be a multi-disciplinary approach to treating chronic pain,” Regan said. “We want to make sure we are not setting up a patient for addiction.”
Dr. Daniel Haight, vice president of community health at Lakeland Regional Health, said that eliminating pain can hide symptoms that clinicians need to know about to make a diagnosis. For example, after surgery a patient on strong pain killers might not be aware of pain associated with an infection starting.
“Once pain is known to be intractable, whether from cancer, nerve damage or some other condition, it can be addressed,” Haight said.
That is the type of pain where opioids are most likely to be used, along with end-of-life care.
Mindset
As hospitals and physician practices develop protocols and guidelines on prescribing opioids and other potentially addictive medications, “we have to look at the perils we are sending people home with,” Vaaler said.
“It is a huge educational effort, a change in mindset,” Vaaler said. “We have been taught over the last few years we have to get rid of pain. But now we have to look at how do we make pain tolerable, offer alternatives and talk to the patients about how medications can harm you.
“We can still address the pain, but we can say to patients, ‘We may not be able to totally take care of the pain, but we will address it and keep you safe,’ ” Vaaler said.
The mindset might stem from how hospitals have been graded on pain management by the federal Centers for Medicare & Medicaid Services. Patients have been asked how well the hospital did at controlling their pain. Starting this month, when patients are surveyed, they will be asked about how well the hospital did in talking with them about their pain.
Until recently, patient answers on pain control figured into Medicare and Medicaid payments. That’s been changed, although patients’ responses to how well the hospitals communicated about pain control will still be part of the Hospital Compare data. The new data will not show up on the publicly available reports for a couple of years.
“When people come in seeking relief for chronic pain, we can look up at the state database. Those who are chronic users of pain medications, we will refer back to their primary-care doctor or specialist,” Vaaler said.
“Opioids are a last resort,” Vaaler said.
Marilyn Meyer can be reached at marilyn.meyer@theledger.com or 863-802-7558.