Spineline - January/February 2017

tive pyogenic discitis/osteomyelitis several years ago. She developed chronic pain requiring long-acting morphine (total of 60mg morphine daily). Her primary care provider managed her pain for several years, but was retiring. No new primary care provider would take on her pain medications. The pain management specialists who were contacted did not want to take on her case either. Most mentioned that they were “interventional pain management specialists” and they did not pharmacologically manage chronic pain. One pain management specialist told the patient he would “get her weaned off the medications pretty quickly.” This statement triggered panic in my patient, who found that her pain would increase fairly quickly if she was even a few hours late for a dose of her medication.

The second patient is a 44-year-old male on chronic opioid therapy (total of 160mg oxycodone daily) for back pain related to an L5-S1 spondylolytic spondylolisthesis that did not improve following an attempted posterior lumbar interbody fusion procedure performed several years ago. The patient’s high dose opioids had been managed by his pain management specialist for the past few years. When the patient came to me, I diagnosed him with a non union and performed an anterior lumbar interbody fusion at L5-S1. The patient experienced a reasonably good outcome from the procedure in terms of reported improvements in his pain and quality of life; however, he remained on high dose opioid medications. He recovered from surgery and left my practice on good terms. This patient contacted me more than a year after surgery seeking help because he had been fired by his pain management specialist for a positive marijuana (THC) result on a urine screen. The patient admitted to his pain management doctor that he had used marijuana, but was still terminated as a patient.

What is this patient to do? If he runs
out of pain medication, he will suffer
and go into withdrawal. In my part of
the country, the vast majority of pain
management specialists are not willing
to take on a patient on high dose medi-
cations who has been “fired” by another
doctor. Is it appropriate for a physician
to abruptly discontinue treating a pa-
tient on high dose opioids for a positive
urine test? Should the pain management
specialist help get the patient into an ad-
diction treatment program or come up
with another solution? There is a short-
age of addiction management specialists
and I also question whether chronic
pain sufferers should be considered “ad-
dicts.” Ultimately, I strictly managed this
patient’s medications for approximately
six months before we were able to find
a pain management specialist in his
insurance network willing to take him
on as a patient.
These two cases are examples of the
large number of patients who are now on
opioids for chronic pain who may suffer
as fewer doctors are willing to manage
these medications.
At last June's American Medical As-
sociation annual meeting, a recommen-
dation was made that pain be removed
as the fifth vital sign. One must presume
that the AMA’s hope is that if you do not
ask about something, you will not need
to treat it. This seems like an absurd re-
sponse to the problem, as asking about
pain simply begins a conversation that
does not necessarily lead to an opioid
prescription. It also ignores the fact that
pain became the fifth vital because more
than 20 years ago, the Joint Commission
on Accreditation of Healthcare Organi-
zations identified the fact that hospital-
ized patients were receiving inadequate
treatment of their pain. 4
Both of the patients described above
remain on chronic opioid therapy and
appear functional with reasonable
qualities of life. As we all are exposed to
the current drumbeat against opioids,
we need to make certain that our pa-
tients remain our priority and that we
use the best available evidence when
making treatment decisions. Clinicians
must deal with the complex challenge of
striking a balance between the benefits
of controlling pain with the risks of opi-
oid abuse by our patients and the public.
The focus now is on the possibil-
ity of overdose, dependence and diver-
sion with opioid use, but none of our
treatment options are without danger.
Acetaminophen use carries the risk of
hepatotoxicity and nonsteroidal anti-
inflammatory drugs (NSAIDs) can result
in death and morbidity from gastrointes-
tinal bleeding.
As the medical community addresses
the current opioid crisis, we need to
recognize that being more careful about
initiating opioid therapy is only one
part of the equation. Properly dealing
with chronic pain patients already on
long-term opioid therapy represents a
challenge that clinicians must face pro-
actively. We desperately need more data
on the efficacy of opioids for chronic
pain and the success rate of opioid
treatment and detoxification programs.
More and better information regarding
the true risks of overdose in chronic pain
patients needs to be made available.
While these data are gathered, clinicians
need to remain compassionate to the
plight of our patients as we adjust our
own treatment algorithms in response
to new information.

References

1. TurnTheTideRx. Accessed October 2, 2016. Available at: http://turnthetiderx. org/.

2. Stack, SJ. Confronting a Crisis: An Open Letter to America's Physicians On The Opioid Epidemic. Huffington Post. Accessed October 2, 2016. Available at: http://www.huffingtonpost.com/ steven-j-stack/confronting-a-crisis-an- o_b_9911530.html.

3. Guideline for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. American Pain Society. Accessed October 2, 2016. Available at: http:// americanpainsociety.org/uploads/ education/guidelines/chronic-opioid-therapy-cncp.pdf.

4. Schneider, JP. No More “Fifth Vital Sign” Is the New AMA Recommendation Helpful? Practical Pain Management. Accessed October 2, 2016. Available at: http:// www.practicalpainmanagement.com/ resources/clinical-practice-guidelines/ no-more-fifth-vital-sign.