3 Day scripts a good idea?
With Governor Hogan’s Heroin and Opioid Prevention, Treatment and Enforcement Initiative being announced in early 2017 there has been a lot of talk recently about the appropriate number of days a narcotic prescription should been written for.
An informative and timely article, dated January 28 2017, written in the Frederick News Post by Frederick physician Dr. Julio Menocal, addressed many of the issues relating to narcotics and opioids prescribing he suggested that a 3 day rule be instituted. One of our Frederick and Leesburg based pain doctors Dr. Chirag Sanghvi and our senior staff have pondered this suggestion.
The opioid epidemic is a very real concern. As the Surgeon General pointed out in his letter to physicians dated August 25 2016, “Since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly – almost enough for every adult in America to have a bottle of pills. Yet the amount of pain reported by Americans has not changed.”
However, expecting your internal medicine/ primary care physician to have the tools to manage genuine long-term chronic pain is unreasonable considering the huge variety of ailments they skillfully treat and juggle daily.
What are the unintended consequences of the 3 day narcotic/ opioid script?
There are many complexities involved in treating pain responsibly. The proposed three-day rule certainly addresses the need for increased monitoring of opioid and narcotic prescriptions.
However, will this rule itself achieve the desired outcome?
With the assumption that terminally ill patients, such as patients with cancer, would not be subjected to the three-day restrictions we must also look at the unintended consequences this rule may trigger:
- Large burdens on waiting rooms and provider schedules as patients fill the books with prescription refill, UDS screen and pill count appointments,
- Additional monthly cost for patients who pay co-pays for every visit,
- Increase in overall health care costs (which may be passed on to all patients eventually),
- Emotional stress on genuine patients who feel they are being treated like drug seekers.
For those who are drug seeking there are other potential consequences to keep an eye out for:
- Potential for increased incidences of “doctor shopping” in neighboring states
- Potential increased theft of medications and break-ins,
- Increase in use of heroin and alternative drugs as opioids become more difficult to obtain.
The three-day rule is certainly a conversation to be had, but perhaps equally as relevant is exploring alternative pain treatments.
Are we taking the right approach?
Many people do not realize that pain management is a specialty itself and is offered as a separate board-certification.
Unfortunately, most people seek specialist pain management care after having suffered with chronic pain for a long time and seeing physicians whose therapies are limited to pain medications.
Chronic pain along with prolonged use of narcotics causes multiple changes in the body such as changes in normal levels of circulating hormones and sleep cycles. These chronic physiologic changes can cause mood changes along with changes to how our bodies perceive pain.
The good news is that there are many alternative pain treatments available. In most cases successful pain management utilizes an integrated approach that encompasses a combination of treatments.
As physicians we recognize that the opioid epidemic is a very real and serious situation. As board-certified interventional pain specialists we also recognize there is a need to treat genuine pain responsibly.
We therefore recommend;
- Using non-surgical, interventional procedures to immediately and effectively reduce pain levels.
- In cases where medication management is necessary; reduce reliance on pharmacologic substances, maintain low doses and do not limit “pain medicine” to strong opioids & narcotics,
- Outline a detailed and carefully designed treatment plan that takes a multi-modal approach to include: weight-loss, chiropractic, physical therapy and/or counselling.
Interventional pain management procedures often enable patients to participate in and get the most out of other alternative treatments such as exercise, physical therapy or chiropractic manipulation.
These therapeutic interventions (procedures) work extremely well at the onset of pain when other physiologic changes have not yet occurred in the body and there is less damage to reverse.
Therefore, the earlier a patient seeks specialist care for their pain the less likely that patient is to be placed on a long-term medication schedule.
Happy Birthday to Us
To mark the occasion of 5 years as Newbridge Spine & Pain Center we thought it appropriate to reflect on the past 5 years by interviewing owner and Medical Director Jay Gonchigar, M.D.
JAY GONCHIGAR, MD
Q: It’s been 5 years since you opened Newbridge how do you feel about the direction of the company?
A: ” I could not have imagined that we would have progressed this far in 5 years. It is a great feeling. We have made great strides in our geographic spread and managed to develop robust clinical and support teams.”
Q: What has been the biggest challenge to the business?
A: “It has been a challenge ensuring both potential patients and the medical community understand what we do. We treat the symptoms of pain, at the source. We do not promise a cure but rather our aim is to help our patients fulfill productive lives free from the burden of constant pain. Ultimately, we aim to improve our patient’s quality of life.”
Q:What has been the biggest challenge you’ve faced professionally?
A: “Professionally the two main challenges I’ve faced are firstly making patients and providers understand the disconnect between the morphology (structural features) and symptoms of pain & secondly managing expectations. In many cases there is an expectation that a successful outcome results in the pain being cured; sometimes that is possible; however, in reality our role is to minimize and manage pain.”
Q:Hind sight is 20/20 – Knowing what you know now is there anything you would have done differently when you started Newbridge?
A:”I don’t think there is anything I would have done differently. As a business owner you learn as the business grows and tweak your processes along the way. Our main priority has always been the highest quality care and personalized treatment for our patients. While we stay true to prioritizing patient care I am happy.”
Q: What are you looking forward to in the next 5 years?
A:”Continued expansion to include additional services and ensuring we continue to offer the most comprehensive range of treatments. We understand that when treating pain we treat the whole the person not just the pain itself thus we would like to outgrow the existing models of interventions and medications as the sole means to alleviating pain.”
Q:What do you anticipate to be a challenge in the future?
A: “Continuing algorithm based medicine when regulatory or other impositions force physician decisions rather than enabling patients and physicians to make decisions based on facts & outcome measures.”
Q: In your view, what are the highlights of the past 5 years?
A:”The creation and growth of our core team who made possible the growth we’ve experienced to date”
Q:What makes Newbridge the company it is today?
A:”Simply put, our patients. Health is a very personal thing and we take it personally. Maintaining our patients trust in us and what we do ultimately defines us as a company.”
New Risks associated with Acetaminophen
In August 2013 the FDA came out with warnings relating to new risks associated with acetaminophen. Acetaminophen is one of the the most widely used drugs for fever and pain relief in the United States and around the world and is marketed under better known brand names such as Tylenol.
The new warnings are linked to three serious skin diseases. Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are the two most serious skin reactions the FDA links, in rare cases, to acetaminophen. Due to these findings the FDA is now requiring that warnings about the possible skin reactions are included on the labels of all prescription medications that contain acetaminophen.
“This new information is not intended to worry consumers or health care professionals, nor is it meant to encourage them to choose other medications,” stated Sharon Hertz, M.D., deputy director of FDA’s Division of Anesthesia, Analgesia and Addiction. “However, it is extremely important that people recognize and react quickly to the initial symptoms of these rare but serious, side effects, which are potentially fatal.”
This is not the first announcement for acetaminophen by the FDA in recent years. In January of 2011 the FDA demanded that the amount of acetaminophen in prescription combination medications be limited to no more than 325 milligrams (mg) in each tablet or capsule and required changes to labeling of combination prescription products. The reason behind this change was due to findings that associated acetaminophen with” potential risk for severe liver injury”.
This milligram limit resulted in changes of dosage and strengths of prescriptions affecting many patients currently using combination medications to manage chronic pain. Combination medications may include opioids such as codeine (Tylenol with Codeine), oxycodone (Percocet), and hydrocodone (Vicodin). Over the Counter medications were not affected by this action.
The FDA has also released a public awareness campaign on Acetaminophen www.knowyourdose.org
Newbridge Spine & Pain Center performs pain management procedures and treatments under a strictly conservative philosophy. Please feel free to contact your Newbridge Pain Management specialist with any questions.
Visit out patient education pages for more information on opioids and to understand the difference between opioid addiction and dependence .
[Source: FDA Consumer Updates http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm363010.htm]