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.
For people with bad back pain participating in summer time activities and exercises can be daunting. On the other hand, many symptoms of bad back pain can be relieved to some degree with physical activity.
Loads of developments offer a pool as part of the HOA amenities but local YMCAs are a good option too. In many cases your local Y will also offer swimming lessons and water based exercise classes. Water is great for rehabilitation as it helps take the pressure off the joints and enables patients to break a sweat while also taking a load of weight off the body.
If classes seem like a bit of a stretch at this point in your rehabilitation schedule then simply wading water at your own pace might appeal to you.
Caution beach-bound vacationers: Easing into a water exercise regime by going to a swimming pool is usually better than jumping straight into the ocean as tides and waves could put unwanted strain on your joints and muscles.
Yoga has many benefits including improved breathing, strength and flexibility. Contrary to popular belief yoga is not just for the ultra fit or flexible it is for those aiming to achieve mindfulness in physical activity and awareness of the mind and body connection. The fitness benefit is an added afterthought.
Summer is a great time to start yoga if you’ve never tried it before because there are plenty of free outdoor yoga classes offering beginner sessions. Here are a few places to check out what’s going on yoga wise:
Southern Maryland yoga on the wharf. This free activity can be taken at your own pace.
Frederick in partnership with Sol Yoga do free classes with “Yoga on the Creek” Thursday mornings during the summer.
Low impact exercises are the key. You’ll get the most benefit from these summer exercises by ensuring you listen to your body and take every exercise at your own pace.
*Always talk to your doctor before starting a new exercise regime.
5 misconceptions about Pain Management
We asked our Doctors to set the record straight and clarify 5 common misconceptions about Pain Management, pain medicine and what we do. Here’s what they had to say:
1) It just entails a doctor writing for pain medications:
Most people have the misconception that pain management specialists primarily and solely write for pain medications as their means of treating acute/chronic pain. This couldn’t be farther from the truth. In fact, it is our goal to keep people from requiring chronic dosing of pain medications as this in itself has long term side effects and changes how our bodies work.
Our intention is to start with an accurate diagnosis of the cause of a patient’s main source of pain and to then implement interventional procedures that can either treat or moderate a patient’s pain. The idea is to either resolve or, at the least, temporize a patients level of chronic pain so that they have more tolerance to physical therapy and require less daily pain medication in the future.
Another common misconception is that a Pain Physician’s use of the term “pain medication” refers to controlled narcotic substances. It is always our initiative to use a combination of different types of medications which are not necessarily narcotics.
As Pain Physicians we avoid the initiation of these pain medications as narcotics carry inherent risks and can become a long term burden on the patient.
There are certain cases where patients have causes of pain that cannot be treated with interventional procedures, and in these few cases we then explore different types and combinations of medications.
We reserve the use of narcotics, for a short time, for cases where procedures do not provide adequate relief, however, hoping not to introduce controlled substances on a long term basis.
2) It’s only for people with neck and back problems:
When people think of pain management, they usually first think of neck and low back pain limited to the spine. Although this can describe a majority of our patients, we also treat many other sites and sources of pain such as chronic headaches, knee, shoulder, abdominal, pelvic pain and facial pain.
We can also treat peripheral neuropathic pain such as that caused by diabetes and chemotherapy or postherpetic neuralgia as a result of having had shingles.
3) It’s a last resort:
Unfortunately, most people come to pain management after having dealt with chronic pain for a long time and seeing physicians whose therapies might be 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. Therapeautic interventions work best the sooner we see a patient as these other physiologic changes have not yet occurred and there is less to reverse.
These chronic physiologic changes can cause mood changes along with how our bodies perceive pain, sometimes making us more sensitive to painful sensations. In short, seeking a consult with a pain specialist as soon as pain persists is the best way to manage your pain in the long term.
4) Pain procedures are only a short term fix and only mask the pain until it returns:
In many cases this statement is actually true. Our goal in interventional pain management is to alleviate or minimize the pain that a patient feels on a daily basis so that they can be more functional and participate in modalities such as physical therapy. Our purpose in pain management is to prepare a patient’s body for building strength so that there are less acute and severe painful episodes.
Although sometimes we are unable to relieve pain completely, we can provide intermittent episodes of relief and eliminate the need for surgery if the patient is a poor surgical candidate or chooses not to undergo surgery.
The longevity of the pain relief a patient experiences depends on the cause of their pain and available therapies that can be offered to the patient. Although some of our therapies do not give prolonged relief, some do.
It is all on a case by case basis, and depends on the age and pathology of a patient’s pain. It is important that patients get assessed by an interventional pain physician to determine if there is a long term relief option for their source of pain.
In many cases, the earlier a patient seeks treatment for their pain the longer their pain relief experience may be.
5) All pain management specialists are the same, if you’ve tried one, there is no use exploring your options with another:
As with any specialty, outcomes are based on a physician’s individual skill and training. Because pain management is an evolving specialty, there are many new procedures that could be introduced to patient’s treatment plan.
Sometimes patients have a failed procedure or had a bad experience and assume that any future interventions will continue to be unfruitful. This is not usually the case. Therefore, it is important to do your research.
Seeking a more interventional driven pain physician who might have more skill or experience in different therapies may be an option to better treat your pain.
Your habits are contributing to your back pain
Sometimes we think that we’re doing everything we can think of to help ourselves and our chronic pain. We’re going to the doctor, going to the gym, eating right and even stopped smoking but can’t understand why we are still experiencing back pain! Here a few simple things that many of us don’t consider, or ignore, that can have a real impact on our day-to-day comfort.
Bad Mattress: The support provided by your mattress makes a big difference in your daily back pain. Spine-Health.Com wrote an article stating that a mattress that does not provide the proper support for your back, “reinforces poor sleeping posture, strains muscles and does not help keep the spine in alignment” all factors that contribute to your back pain. Often you can train yourself out of poor sleeping posture. In my case I’ve found I have a better day if I’ve slept on my back rather than my stomach with my neck turned to the side. Therefore, I consciously tell myself to sleep on back each night and position myself to do this as I prepare for sleep – when I achieve this, and I’m getting better every night, the difference I feel the next day is remarkable.
The way you get out of bed: This is a game changer for me! If you’re jumping out of bed because you missed your alarm or pressed “snooze” too many times and are running late, well, sorry to tell you but this action can put your muscles into spasm and result in some serious myofascial pain. I did this about a week ago and felt the aftermath for three days. Even if you’re late consider that taking a little extra time to allow your body to wake up will prevent you from ruining your whole day.
TIP: One way to calmly wake your body up is to roll over on to your side and use your hands and forearms to push yourself into a sitting position as your slowly swing your legs over the edge of the bed, pause for a moment and then drop your feet to the ground and slowly stand up.
Clutter: Loading your back pack or hand bag with too much clutter means that you are carrying around extra weight, and probably not evenly distributing that weight across your shoulders either. Clean out your bags every evening and don’t lug around unnecessary stuff.
Your posture while on the computer: You’ve probably heard this a million times (I’ve heard it a million times) but this truly makes a difference. Maintaining the correct posture while at your computer, especially if you work in an office, can change your week from painful to painless. Take a moment to check yourself (before you wreck yourself) now.
High heels: Ladies we’ve written about how high fashion hurts before. But remember those Jimmy Choos might look pretty but your spine & back are not impressed. If you’re going to an event where you know you’ll be standing for long periods of time or having to walk a long distance select some shoes with a little more support such as a wedged heel. Additionally, there are a number of gel cushions on the market that can make those shoes a little more bearable.
Your Wallet: Guys putting your wallet in your back pocket and sitting on it throughout the day tilts your hips and results in uneven and incorrect sitting posture not to mention the bulky wallet puts pressure on the muscles and nerves, such as your sciatic nerve, lying underneath. Take it out before you sit.