A Pain Specialist’s Perspective formulary. Buprenorphine is a partial opioid. It is safer than full opioids but can still give significant pain relief. Its coverage and access need to improve. It will save more lives. Pain treatment done right is not quick and it is multidimensional. It involves much more than just a trip to the pharmacy to fill a prescription for pain medications, opioid or non-opioid. But what has happened is that so many clinicians have had only pills, particularly opioids, in their arsenal to treat their patients’ pain. The opioids have sometimes served as a virtual band-aid. Other modalities have been out of reach for many patients, and continue to be. By the time the patient arrives at the pain specialists’ door, often they have been covered with many minimally helpful band-aids and are still not doing well. Many do not have a clear diagnosis. “Low back pain” doesn’t tell us anything about the pain’s etiology or point us in a direction for an effective treatment. Oftentimes it becomes our task to unpeel all those band-aids—working to taper down on the dose and, for some patients, assess and find treatment for addiction disorders. This service is becoming less and less covered, and it remains to be seen how the imminent spike in people seeking or needing these services will be addressed. A number of patients are under-resourced, underfunded, or have low health literacy. There is a clear psychosocial dimension of chronic pain. It can profoundly impact the patient’s mental health. Depression is almost ubiquitous in chronic pain patients at some point in their journey. Very often the psychosocial changes affect the patient’s family as well. Getting mental health issues properly diagnosed and treated is another integral component of comprehensive pain care, and is itself fraught with coverage limitations. Laura Scobie, PA-C, a member of the OMA’s Opioid Task Force, has practiced with Columbia Pain Management in Hood River since 2004. She serves on the Oregon Pain Management Commission, as well as representing the commission on the Prescription Drug Monitoring Program’s Advisory Commission. For more information about the PA Section of the Oregon Medical Association, please email joy@theoma.org. Oftentimes it b becomes our task to unpeel all those band-aids———working to taper down on the dose and, for some patients, assess and find treatment for addiction disorders. PHYSICIAN ASSISTANTS By Laura Scobie, PA-C I JOINED THE OREGON PAIN MANAGEMENT COMMISSION five years ago as a patient advocate in the treatment of pain, and I am still part of the commission, but after the big upswing in opiate overdoses changed the environment, the safety side of the equation has come to the forefront. In my opinion, balancing patient advocacy and safety is the central issue in pain management today. A lot of focus has been placed on developing prescribing guidelines and emphasizing upper-limit, morphineequivalent dosing. This dosing level is a tangible, measurable data point, which many large health systems like to track. For the bulk of patients (the “bell” of the curve), these limits are appropriate and has improved patient care and safety on the whole. However, for the “long tails” of the curve, things become less clear. Many patients with bona fide chronic pain conditions from injury or disease are very stable on doses higher than the designated “line in the sand.” They have maintained significant improvement in function level, decreased pain, no adverse effects, and no aberrant behavior. If you decrease their dose, some do okay, but for some, their quality of life dives. Some people in this cohort have had great difficulty keeping prescribers as more clinicians worry about possible board action surrounding opioids. Our clinic in Hood River has seen patients from as far away as Coos Bay searching for a clinic to continue their medications. I’m also concerned about system barriers such as insurance. For example, in many instances insurance won’t priorauthorize a safer, schedule III medication until the patient tries and fails less-safe schedule II medication on the carrier’s 20 Medicine in Oregon www.TheOMA.org
OMA Medicine in OR Winter 2015 2016
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