A Country Doctor Writes:

It feels like we are moving backwards!

(This is going up on my Substack tomorrow. Links to older posts on the same topic below.)

In the beginning of the opioid epidemic, pain became the fifth vital sign, and we all know what happened after that.

The prescribing guidelines became more restrictive. States and national authorities implemented dose limits. The monitoring of physician prescribing practices and the shaming of physicians who prescribe more opiates than their peers is systematic now.

A Country Doctor Writes: is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

And yet, even though opiates have fallen out of favor and many of the non-opiate pain medications have at least come under suspicion, if not downright gotten viewed as inappropriate, we are now required by CMS to make ongoing pain assessments.

Lyrica is a controlled substance, its sister drug gabapentin has become popular with substance abusers, Cymbalta can cause mania, amitriptyline is viewed as inappropriate for the elderly because of side effects, largely anticholinergic. Cyclobenzaprine falls in the same category and requires prior authorization over age 65 with many insurance companies. NSAIDs can cause gastrointestinal hemorrhages and kidney damage and Tylenol had its maximum dose recommendation reduced several years ago because of concerns for liver damage, and so on…

So if we screen for pain with positive findings, there is no obvious, easy and safe intervention to offer. Considering that this is a throw-in when patients are actually being seen for something else, this is a prime example of Pandora’s box.

The common sense approach to screening is that it should be done when there is an effective intervention that can be offered. CMS did not in the past recommend screening for depression, for example, unless mental health resources were readily available. They changed their mind on that. But, where I work in Northern Maine, most therapists have a one year waiting list or worse. And the dirty little secret about antidepressant medications is that they work about 30% of the time – about the same as placebo.

We are mandated to screen for pain with no easy treatment options. The foundation for pain management is largely cognitive behavioral therapy, which is hard to come by as a modality that requires special skill on the part of the behavioral health counselor.

As far as interventional pain management, lumbar steroids etc., the outcomes data is mixed.

So here we are, beginning a routine visit with a patient who scores positive for pain and depression. Meanwhile, their blood pressure, blood sugar or whatever is out of control. The medical provider’s internal egg timer is ticking. How can we best help this patient in the limited time we have available?

Thanks a lot, Uncle Sam…