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Opiates: Are There Any Good Answers? Part I

The opioid ‘epidemic’ is not really an epidemic at all.  It is an unfortunate, but predictable outcome.  At the turn of the century, the cry was to make pain the 5th vital sign and JCAHO released pain standards to be used after much public outcry and a national desire to address pain.  Mostly short acting opioids existed then and pharma responded with more meds and even created ‘abuse deterrent’ agents to help avoid illicit behavior.  The race was on to treat pain.

From primary care to pain practices the new enemy was pain.  From hospitals to outpatient practices getting pain under control was the key.  In 2001, I was just opening my private practice specializing in osteopathic manipulative and regenerative medicine.  By week six I was at six-month benchmarks and business was booming—and I was not writing many pain meds save for post prolotherapy injections. 

The key was functionality.  My objective was and is to make pain patients more functional.  In a pain practice or any practice treating pain, function, not pain, is the outcome to be measured.  To be clear osteopathic manipulative medicine was the majority of my work.  Historically DOs were slow to join pharmaceutical prescribing with AT Still flying the cautionary flag and osteopathic manipulative medicine grew in popularity, but literature was mostly empiric and his concerns prophetic.

Success begets more patients and more business.  As we grew, pain management, utilizing opiates and a core risk mitigation strategy:  opiate agreements, pill counts, and three phase urine drug screens along with other adjuvants really made a big difference in my patients’ lives and in their functionality.  OMT was still the core of our work and our point of notoriety, but using it in combination as a tool along with injections, medical management and solid clinical examinations was enormously helpful to our patients and our practice grew rapidly. 

The current ‘crisis’ was a predictable and avoidable one.  Many practices do not do appropriate risk mitigation when prescribing controlled substances nor do to they do appropriate risk stratification prior to commencing controlled substances.  The headlines across our country make that pretty evident.  We are not just talking pain meds, but that includes amphetamines for ADD/ADHD and/or benzos for ‘anxiety’ that may be best controlled via serotonin (5-HT) replacement—remember anxiety symptoms are the first symptom of 5-HT deficiency.  Moreover, well intentioned state statutes setting arbitrary limits on morphine milliequivalents (MME) and how long someone could be treated drove legitimate patients to the streets.  48% (80% by some studies) of patients using street drugs use them for pain conditions their providers can’t or won’t treat.  Once their dealer has no more oxycodone or hydrocodone or it is priced too high, heroin is the cheapest opioid analgesic available, but the consequences have and continue to be deadly.  This too was predictable and legislative bodies were warned as history can and does repeat itself. 

Body, mind and spirit are the triad upon which osteopathic treatment is based.  The core tenets require us to consider these elements identifying ‘rational’ treatment related to structure and function.  Shoulder pain may not be a glenohumeral joint issue, but a rib somatic dysfunction affecting the scapulothoracic joint (pseudojoint).  It might even be a sacroiliac strain from a long drive that caused the shoulder pain made evident when the driver yanked her suitcase out of the trunk after her sojourn.  Osteopathically trained physicians have the inherent capacity to delve into the causality of the pain and not simply inject a prepatellar bursitis because it is there.  The ‘why’ it’s there is the etiologic query a solid DO would ask and identify.  Perhaps the pes planus secondary to the dropped navicular from walking barefoot on the beach the day prior to her long car ride was and is the cause.  Treating the navicular will normalize gait and the bursitis should resolve in due time.

However, in some instances the injury may not resolve even with solid osteopathic management.  As I often remind residents and students, we are physicians first.  OMT is one of our tools.  We need not and should not rely solely on manual medicine if it has failed or when another treatment option may be a better option.  In our zeal to ‘prove’ OMT or show its worth I have often seen colleagues futilely use manual techniques when a non-OMT treatment may work better.  Doing the same thing over and over again expecting a different outcome is the definition of insanity.  Doing that with OMT is no different.  If documenting functional maintenance or improvement or measurable pain reduction via visual analogue pain scales, then recurrent OMT may be justified.  Federal quality measures exist to prove and memorialize this logic and validate treatment.  This evidence is vital to our osteopathic and fiscal survival.  Osteopathy is over 100 years old because it works.  Yet we must prove its worth by collecting data and proving efficacy via outcomes or we risk access to care for our patients.

As DOs, we encapsulate the comprehensive treatment paradigm.  Osteopathy is not just manipulative medicine, it is a philosophy based on allowing the body to heal itself.  However, in some instances, when that is not possible, our unrestricted license to practice medicine and surgery warrants further interventions in our patients’ best interest.  These interventions, the likes of which I have used the last twenty years, could be pharmaceutical, injections, surgery, PT/OT, or even alternative treatment options.  Osteopathy includes OMT, but not to the exclusion of other treatment options where applicable. 

In the end, the fact that our patients need to regain functionality must be in the forefront of our clinical decision-making for that is exactly what they deserve.

 

Click this link for Dr. Jorgensen’s web page 

9 Responses to Opiates: Are There Any Good Answers? Part I

  1. Linda Tate October 10, 2017 at 8:52 am #

    Sorry for the delay in getting back to you…my husband had surgery so I’ve been taking care of him. Thank you for your patience, much appreciated! Here’s the good Doctor’s response:
    Great question and exactly why Patient360 (a company that I founded) became a QCDR. The ‘worth’ of OMT is of inherent value to the patient, but considered a ‘medical loss’ by the insurers. Insurance companies lose money when they pay beneficiaries bills. It’s a fact irrespective of the type of insurance. Auto, health, homeowners, pet insurance all lose money to cover beneficiaries’ use of the insurance; as such, it needs to be justified. Insurers—again, all types of insurance with health insurance included—risk adjust to optimize their income and avoid claim payment whenever possible. To prove worth, quality data metrics must be collected as the research literature is not adequate to make this argument. That is multifactorial, but the focus on treating patients, improving functionality and avoiding other diagnostic and therapeutic interventions must be documented, culled and analyzed so we can prove to the federal and private insurance organizations that what we do is not only worthwhile, but cost effective. Patient360’s Quality Clinical Data Registry (QCDR) does just that and we have the only manipulative medicine measures in the entire Quality Payment Program (QPP). If every DO in the country did one measure in our MIPS-4-Beginners (M4B) program, we would have tens of thousands data points and could build on that to prove efficacy and cost savings. Making pleas to local insurers and Medicare Administrative Contractors (MACs or your regional Medicare provider) to write policy to include OMT helps, but definitive proof will come in data analytics proving efficacy and cost effective care. This is what we must do or we may lose the ability for OMT to be a reimbursable service. It is a moral imperative that osteopathic physicians work to prove ‘the worth’ of osteopathic manipulation or your insurance companies request will become an edict where payment for OMT will cease to exist.

  2. Linda Tate October 6, 2017 at 11:21 am #

    Great question! I will forward this to Dr. Jorgensen…

  3. T Hammer, DO October 6, 2017 at 11:05 am #

    Just wondering how an individual physician can,(when requested by Insurance company ), “… prove its (OMT) worth by collecting data and proving efficacy via outcomes” lest “we we risk access to care for our patients.”

  4. Linda Tate October 4, 2017 at 2:22 pm #

    Scott, I agree. Having worked in Social Services for 20 plus years, I’ve also seen what you describe… I will send Dr. Jorgensen your response, and thank you.
    ~Linda Tate

  5. Linda Tate October 4, 2017 at 2:21 pm #

    Thank you for your response! I will forward it,
    along with the others, to Dr. Jorgensen. It has been approved to display on our blog.

    ~Linda Tate

  6. Scott R Dolan October 4, 2017 at 1:42 pm #

    Given Dr. Jorgensens point of “functionality” as a focus rather than a mere outcome to treatment, I have been blessed to see the positive and negative results as a functional assessor for a public transportation company who receives <70% of their applicants from primary issues related to conditions that cause pain – preventing them to walk or transport themselves. In my experience and from an outside healthcare perspective, the greatest frustration hear in the voices of many are due to poor treatment options/plans to subside the very dysfunction that is causing the pain. Options like OMT, massage, kinesiotape, acupuncture, and more are rarely ever heard as (at least attempted) treatments to addressing the core issue (an often obvious one too like arthritis) are never mentioned. Having done this job long enough, and unsurprisingly, I [un]fortunately get to see re-certifications with individuals who haven't gotten any better, but worse instead. Indirectly, the other reasons for limits in treatment plan options are due to healthcare limits and SES circumstances.

    It is more apparent everyday that those who live longer without proper functionality (ADL's) to their daily living never get better – despite their subjective level of pain "feeling" better. Those that do almost always experience a decrease in pain and an overall better appreciation for how they are able to get from place to place.

    Thanks for the great blog and well-needed conversation.

    Scott Dolan, MS, LMT

  7. Lindy Sue Griffin, DO October 4, 2017 at 11:58 am #

    Are there any good answers? As an practicing Osteopathic physician in my fourth decade of practice, I can say this is a cyclic phenomenon. When I first started practice in the 1980’s, we were encouraged to not use opiates. In the 1990’s pain was considered a vital sign and we were encouraged to do what ever was necessary to alleviate pain. This makes sense to me in that it stops the initiation of the chronic pain cycle. However, as an Osteopathic physician, I had many tools to work with, including OMT. In the 1990’s it was predicted that due to the AIDS/HIV epidemic and fear of contagion,IV drug use would go down. And, it did. It was also predicted that as we got a handle on HIV the use of IV drugs would increase. This also happened. I am sure the “great recession” making less expensive heroin more attractive helped it along. Politicians then seemed surprised, and decided to attack this epidemic. There was much a do about this including non-medical personnel making medical decisions, and those from other countries coming in to tell physicians what to do. The most important thing here is the patient’s pain seems to have been forgotten. I think the majority of physicians are conscientious enough to do a good history and physical to diagnose the patient’s problem. Multiple modalities are almost always required to help.

    A “good answer” would be something that was 100% effective, and had no side effects. I do not know of anything like this. It is always good to be reminded of the side effects of things and look for better treatment. However the patient is the most important part of the equation here. In our search for the “good answer” we must not forget them.

    Lindy Sue Griffin, DO

  8. Linda Tate October 4, 2017 at 9:16 am #

    Thank you for your response! I will forward it to Dr. Jorgensen. It has been approved to display on our blog.
    ~Linda Tate

  9. Domenick J Masiello October 4, 2017 at 6:14 am #

    For the past 30 years I have treated all my patients with OMT and Homeopathic drugs. I have written one prescription for an opioid in the past 30 years. I do sometimes prescribe NSAIDS. This is how I treat pain. My post- partem patients do not require conventional pain drugs other than Tylenol. This is true for both vaginal deliveries and C-Section patients. My surgical patients require far fewer doses of opioids and the hospital staff is amazed as my patients turn down pain meds. Dental patients are routinely treated with two homeopathic medicines for dental extractions, root canals and dental implants, all without opioids. Plastic surgery patients are treated with one or more homeopathic drugs to avoid pain/numbness and the “raccoon eyes” so common after a face-lift. NYC plastic surgeons now routinely prescribe Arnica to their patients. I use homeopathy to help my kidney stone patients pass stones with little or no opioid use. I use homeopathy to decrease the needs of opioids in my metastatic cancer patients. Recently, I have added a new modality to my practice – FSM (Frequency Specific Microcurrent) a two channel.4 electrode system where one channel corresponds to the physiological condition and the other channel to the tissue. This has been great for pain patients: metastatic cancer pain, femur fracture pain, IBS pain/cramping. he uses are virtually endless, osteoarthritis pain.

    Domenick J. Masiello, DO, DHt, C-SPOMM
    Adjunct Assistant Clinical Professor OMM TouroCom – Middletown

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