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Lessons Learned in Measuring Pain and Prescribing

A roundtable discussion from the California-based Cooperative of American Physicians

With T. John Hsieh, MD, Medhat Mikhael, MD, Charles P.  Steinmann, MD, and Jae Townsend, MD

The Cooperative of American Physicians (CAP) offers medical professional liability protection and risk management services to nearly 12,000 California physicians. Recently, the group held a clinicians' roundtable called “Pain Management in the Crosshairs” to anecdotally discuss their careers in pain management, from measuring pain across diverse populations, to safely prescribing in a culture of pill-popping, to challenges with insurance and in the differences between patient expectations and physician expectations. The following transcript is published with permission from CAP. Participants included:

Moderator: Carole A. Lambert, MPA, RN, vice president and program director of practice optimization, CAP

Discussants:

Charles P.  Steinmann, MD - an anesthesiology specialist in Costa Mesa, California. He earned his medical degree from the University of California, San Francisco, School of Medicine and has more than 47 years of medical practice experience. Dr. Steinmann is affiliated with several hospitals, including Hoag Memorial Hospital Presbyterian in Newport Beach, CA.

T. John Hsieh, MD - a board-certified anesthesiologist and interventional pain management physician based in Irvine, CA. Dr. Hsieh is affiliated with Newport Harbor Anesthesia Consultants and earned his medical degree from the University of Kansas Medical School. 

Jae Townsend, MD - a board-certified anesthesiologist affiliated with Huntington Hospital in Pasadena, CA. She received her medical degree from University of Tennessee College of Medicine.

Medhat Mikhael, MD - a double-board certified anesthesiologist and pain medicine practitioner. Dr. Mikhael is director of the Pain Medicine Division, Department of Anesthesiology, at Hoag Memorial Presbyterian Hospital in Newport Beach, CA. He is also an active member of the cancer committee of Hoag Memorial as well as the Long Beach and Orange Coast Medical Centers.

 

Ms. Lambert: Dr. Steinmann, [can you get] the ball rolling by sharing a brief historical perspective on the challenges of pain management while you have been in practice?

Dr. Steinmann: The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain protects us from injury and disease. Fact is, we always will have to deal with pain. The trick is once the injury or disease is recognized, how do we shut off that response?

In one of the earliest recorded pain treatments, the ancient Egyptians used beer for surgical procedures. For the last few centuries, the gold standard for controlling pain has been morphine. By the time of the Civil War, general anesthesia – ether or chloroform – was used in over 85% of all amputations on the battlefield. During the mid-20th century, multiple other mechanisms began to be used such as local anesthesia, pain blocks, acupuncture, antidepressants, pain pathway inhibitors like gabapentin, and anti-inflammatories.

By the late 1990s, it was still easier for prescriptions for pain medications – such as Vicodin or codeine – to be written that way. At the same time, multiple pressures were put on the physician to prescribe more. Because of the problem of addiction, now we are under pressure to prescribe less. 

Dr. HsiehI’ve watched the pendulum swing throughout my career. In 1980, a letter to the editor was sent to the New England Journal of Medicine, stating that treating pain patients with narcotics would not cause them to become addicted to narcotics. This was a revolutionary statement, and that letter - with its observations and conclusions - became the most cited publication for the treatment of pain and influenced how physicians prescribed opioids for the following 25 to 30 years.

But, pinpointing where and when the use and abuse of addictive substances really took off is difficult because our society has historically been a society of using pills. In the years I was going through high school and college, the use of cocaine and ready access to prescription drugs was obvious. It’s very hard to say that physicians promote pill popping when it is such a part of American society. And there is the economic reality that prescription medications are big business, which has to be part of any attempt to deal with substance use and abuse.

At the end of the day, pain is very difficult to measure. It is ultimately subjective and unlike any other vital sign in that there is no real measuring device you can use. When you're treating pain, it is based on the patient’s perspective and sometimes a lot more complicated than it first appears.

Dr. Townsend: My experience in collecting historical information for a patient going into anesthesia and then receiving post-op care just underscores the fact that every human being is wired differently. So the wiring of a female is different from a male. A person who has had past experience with pain throughout their whole life, or just even early in childhood, has different wiring than an adult who has no experience. As a society, as a culture, I encounter people daily who are about to undergo surgical procedures and have an unrealistic expectation that they're going to have zero out of 10 pain post-operatively. So as a society, we've set ourselves up to have an unrealistic societal expectation that you're never going to have any pain or suffering. We are a culture of pill poppers.

People have pills for every single thing from slight anxiety or slight depression to minor discomfort. Granted, there are plenty of times that this is warranted and appropriate, and I'm not undervaluing that at all. But we have to undergo nothing short of a cultural revolution in which we, as physicians, educate people that it's unrealistic to expect no pain. I typically tell my patients that we're going to have controlled or managed pain after surgery. 

Overprescribing originated due in large part to instances in which physicians were held accountable for patients with uncontrolled pain. Specifically, end of life, death, and dying. There was liability, there was accountability, there were physicians who were sued. In consequence, I think clinicians overreacted and began overprescribing because they were afraid of having patients complain about there being under-prescribers.

Let me just add to that opioid use in the United States has consistently been the same. We just had opioid use that was prescription opioid use. Whenever there wasn't a lot of prescription opioid, there was a lot of heroin. Now that there's less prescription opioid, there's more heroin. People in this culture, in this society, are addicted to opioids and we have to have a societal change.

As an anesthesiologist, to prepare patients, I do a lot of education about realistic expectations. I tend to refer to opioids as the poison. I'll give you some of the poison, but we’d like to get you off the poison as soon as possible. Sometimes, you need a little bit of the poison, but we're going to try to minimize it and create a situation where we use all sorts of alternatives so you need as little as possible. 

Dr. Mikhael: You know, there is a huge unrecognized role of other medications in the increasing death rate from overdoses. The common factor among all these patients is how polypharmacy has contributed to a lot of the accidental deaths that have happened.

For patients with chronic pain, we may start by adding anti-seizure medications. Then we might add antidepressants. Some clinicians like to use anti-anxiety agents that they believe affect muscle relaxation. These medications contribute to depressing the central nervous system and, as a result, they can depress respiration and can lead to an overdose and death. This point that has been addressed in the CDC guidelines, particularly with benzodiazepines and of the synergistic effects of drug combinations. Our patients ask why we want to review and maybe modify their medications when they have been on, say, Ativan and Norco for years without any problems. We tell them that if the patient is at a weak point – in any given day they were dehydrated, they had a flu, they were malnourished, they were sick for any reason – the combination of these medications was too much for them to handle and they ended up with an overdose or dying.

So Dr. Hsieh and Dr. Townsend talked about the pendulum that has swung from one extreme to the other because the designation of pain as the fifth vital sign puts pressure not only on clinicians, but also on hospitals. If the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score showed that patients rated you as controlling their pain well, your reimbursement was impacted positively. But if the pain score was down and the patient was below extremely well controlled, the reimbursement rate was negatively impacted. Now the government is recognizing this wide variation and its impact, so the 2018 changes to HCAHPS moderate the measure.

That shows you how the pendulum has swung. But we clinicians are challenged to care for our patients, to respond to their concerns, to prescribe and refer appropriately, all in an atmosphere of intense scrutiny and potential liability. We all need to continue to educate ourselves and then educate our patients.

Ms. Lambert: Dr. Steinmann, you have a very active pain practice and you do injectables as well. Tell us about the patient education efforts in your practice and the staged interventions that you use, even in the face of patients’ demands for ultimate treatment.

Dr. Steinmann: Well, we try to answer the questions of how to protect the physician and the patients. My approach is, first of all, when you first meet a new patient, you have to document. Having worked with CAP’s Mutual Protection Trust (MPT) on many cases, the biggest thing is communication closely followed by documentation. Dr. Mikhael has noted a real problem: We're given a pain patient and a situation where we may not have the time to be able to give him the full education. But it is our duty to communicate with the patient. I think communication is half the battle of a treating a pain problem.

There are things that are helpful for us as physicians. The Controlled Substance Utilization Review and Evaluation System (CURES) system is excellent to follow up to find out if patients are having other doctors write prescriptions. An agreement, whether oral or written, between the physician and patient is a good topic for us to talk about as well. But my basic plan is: the last thing I'm going to do is give a narcotic. So, I tend to start with anti-inflammatories.

I tend to use obviously injectables, like pain blocks and even oral steroids, before I would opt to going to any narcotic, even Vicodin. And I've been relatively successful in doing that, but then again you have to look at the patient match. I tend to get patients that might be less pill-driven than other physician practices. 

Ms. Lambert: Dr. Townsend, you are a pediatric anesthesiologist. There's always been a concern about children being under being treated for pain. How do you approach achieving an assessment and a treatment plan for a child in pain?

Dr. Townsend: I do acute pediatric pain management as well as anesthesia. Children are really different from adults, and the younger the child, the more so. For example, a premature neonate has a different physiology than a full-term neonate. We know because there have been very eloquent studies done that have proven that children exposed to early painful experiences become adults who have poor mechanisms to control pain later in life. I also am involved with fetal surgery and we're not really sure exactly when a fetus starts to develop their top-down regulatory mechanisms, but we know they’re certainly not there when we're operating on one at 16 and 17 and 22 weeks of gestation. So, we're providing analgesia that crosses the placenta to prevent painful experience.

Studies have been done comparing children who had immunizations. All kids in the US get immunizations at two, six, and 10 months and it hurts, but who cries the most? Other studies compare boys to girls. Boys who were circumcised with anesthesia were compared to boys who were circumcised without. Boys who undergo circumcision without anesthesia cry longer and harder and score inordinately higher on pain skills consistently through their childhood. So, we changed our medical practice based on studies like this from the ’80s. We started providing anesthesia for little, little children undergoing circumcision. Hopefully, you prevent a lifetime of enhanced pain perception that way. Interestingly, the kids who felt the least amount of pain were girls, and you would think girls and uncircumcised boys would be the same but they're not. That’s because little girls, when they are born, have high levels of estrogen, and estrogen is very analgesic.

Dr. Hsieh: My experiences with my patients have prompted concerns about the cellular, the metabolic effects, of prolonged pain medication administration. If you have ever seen and evaluated a patient who has been on long-term narcotics, your assessment will reveal how they have changed. Research shows that the changes start at the cellular level and get amplified when you lead up to a whole. The patient’s perception of society changes. Daily behavior changes. Rounding out a comprehensive assessment is challenging, but getting one makes it possible for a physician to make a difference with patients. When a patient comes to you saying they want to be treated for their pain, educating them about what’s happened to them, talking about what their goals are, and managing their expectations will be key.

Dr. Mikhael: I agree. We have a step-by-step approach. I may evaluate a patient who has not been on narcotics before, and feel that this patient is a legitimate patient to be on pain medications whenever needed. 

I have to have an agreement with the patient with multiple points: I am the only prescriber. They cannot ask for early refills. They cannot share these medications with anybody. They cannot take medications from anybody else. They are very centered about using one pharmacy only. The prescription comes only from us. They agree to have a random urine screen done on our premises.

We also make sure we obtain informed consent with detailed discussion of possible side effects. We run a CURES report. We manage pain patients in a tight fashion. The patient understands that we are monitoring them closely and that we're working toward treatment approaches to help their pain and get them off medications

Dr. Steinmann: We’ve learned some lessons here at CAP that we can carry forward to protect physicians and patients. The first thing is documentation. Whether it’s pain management, surgery, or just medical care in general, it may be difficult but has to be done. Communication is probably the second most important thing and that comes back to the patient’s goals and expectations. For instance, there are a lot of patients who will come in having had chronic back pain for many years and may have had laminectomies. Their pain levels when they come in are an eight out of 10.

We talk about why don't we try to make a goal of four out of 10. If we can make a goal of four, that will be a victory and we talk about that. And 95% of the time, they’ll say, “If it gets to a four, okay - I might be able to live with that,” and that would be a victory. Well, that to me is an achievement and if you get better than a four, then you are a super winner and they love you forever. So, having expectations that are within reason, using available tools and controls, and effective communication and documentation are very, very important.

Also, I think a lot of things can be covered without narcotics. I am more and more impressed as time goes on about the use of anti-inflammatories. Certainly, going back to the operative situation and using the anti-inflammatories for certain surgeries, once you know that there's not a bleeding problem, Tramadol has been and is a terrific drug. Toradol is also a terrific drug, especially for use with laparoscopes. 

Let me just say that we hear today that there is a drug problem now, as if there wasn't in the past with opium and cocaine. There are a lot of things in motion here, and medicine is still an art, not a science.

Dr. Mikhael: A big problem with a big impact is that a lot of payers have issues or problems covering behavioral health and addiction treatment. So, you get a patient who agrees with your terms, agrees with the plan, and accepts the risks. The patient may be fearful, but agrees that he or she needs help. Then, you go to the health plan and say, “I need a psychologist to see the patient,” or, “I need a psychiatrist to take care of that patient because as we get him off narcotics, he’s going to be depressed,” or, “I need an addictionologist to help me to get him off that stuff he's been on.” Then, all of a sudden you find that behavioral health and addiction medicine are not covered benefits for this patient’s insurance. It’s a challenge for us as clinicians as we try to take care of patients and practice safely.

Ms. Lambert: Dr. Townsend, you see people. They have general anesthesia. They come out, they have finished their procedure, but you must be interacting with families a great deal. What about the patients who are not on the census – the families?

Dr. Townsend: We approach this as a constellation of biopsychosocial/spiritual factors. When we treat a child, we don't just treat the child – we treat the child's family, as well as his or her social environment. It is absolutely essential to have everybody on the same page. For children, we get a lot more mileage out of prevention of pain, and I would say the same is for adults. You know, we talk a lot about pain management, but we need to have lively and abundant conversations about pain prevention. So, we do lots of things in anesthesia such as regional blocks to prevent the experience of pain, so you don't have those apparent pathways that get set up – whether it's wide dynamic range neurons or complex regional pain syndrome. These are things that may happen when you have a painful experience that's not prevented or initially managed well.

Dr. Hsieh: As chair of CAP’s anesthesia/pain management risk assessment peer review, I can say we’ve learned a lot. I have been doing case reviews for more than 10 years, and I know I am more careful in my own practice. What I have seen over and over is that the number-one cause of lawsuits around pain management is failure to manage patients’ expectations. Patients’ expectations are different from their physicians’ expectations. And patients’ expectations of pain-management physicians are different from their expectations of other physicians. This is where communication in all its forms – education, informed consent, pain contracts – is so important. So, when patients feel they haven’t had all their questions answered, that the physician has kept information from them, that there's a lack of transparency, the patients were more likely file a claim. That's my perception, number one. 

And my perception number two is the critical importance of documentation. A lot of physicians, for one reason or another, fail to document what is going on with the patient. They get busy. They forget. For whatever the reason, they fail to document exactly what happened when it happened. Rarely – and it never ends well – a physician will add to or edit the record. That doesn't happen too often, but we have seen it.

So, at the end of the day, document as truthfully as possible, and as carefully as possible. And finally, when an issue comes up, it's always a good idea to call CAP’s hotline and a talk to a risk management and patient safety specialist. They will give you a very concise and correct pathway for you.

Dr. SteinmannThat's excellent. I'm glad you brought up the CAP hotline, because that is a unique thing that we do and, believe me, it is very helpful for the clinicians.

Ms. Lambert: As for final thoughts...

Dr. Hsieh: Just a caveat for all of us to think about: all of us involved in healthcare – clinicians, entities, systems, industry partners – share the responsibility to work together to reverse the substance use and abuse patterns. This means, among other things, being willing to pay for the professionals, the tools, the alternative treatments. It means being willing to advocate for those resources. No one factor is responsible for the rates of addiction and the rates of death by overdose. No one factor is the answer. Everybody needs to be part of the solution.

Dr. Townsend: I just want to dovetail on what was said about documentation. Your record and what you document is what happened. If you didn't write it down, it didn't happen. So, as a treating physician for pain patients, it is just imperative to always keep a record.

Dr. MikhaelI always tell students and young doctors: treat your patients exactly like you're treating your own family members. If you think that way all the time, patients not only will love you and trust you, but your liability will be reduced. Definitely, this is in addition to what others have said: document, document, document.

Ms. Lambert: Dr. Tom Nasca, CEO of the Accreditation Council for Graduate Medical Education, said in a presentation a couple of weeks ago, that we are preparing the prescribers of the next 40 years. So, everything that we do with the young physicians, young clinicians who come within our orbit, is going to pay off in the future for a more balanced approach.

 

[end transcript]

What’s your take on this dialogue? Email the editor at ppmeditorial@verticalhealth.com

Last updated on: July 27, 2018
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