By Janet L. Hurley, MD
Earlier this year, I had the privilege of representing Texas family physicians at a conference sponsored by Superior Health Plan called “Changing the Paradigm in the Treatment of Chronic Pain and Substance Use Disorder in Texas.” As a middle-aged primary care physician who grew up in the era of “pain is the fifth vital sign,” I was frustrated by some comments made by legislators and health care policymakers, many of whom are not primary care physicians and have no idea what it is like trying to apply new pain guidelines to patients who are suffering. It is time to empower primary care physicians with the tools needed to manage these patients humanely and safely.
The patients we worry the most about, who have had childhood traumas and diffuse pain syndromes, often take combination drugs like benzodiazepines and opiates, and are some of the hardest to treat. We are told by new CDC guidelines that we should try to minimize treatment with these drugs, yet these patients often have intense psychosocial needs that our medical communities are not equipped to address. Experiments done in other areas where physicians made a firm stance against ongoing prescribing have sometimes led to higher overdose deaths from illicit drug use.
While it is true that patients may be more functional and feel better overall if we successfully wean them off of their habit-forming medications, doing so without a supportive infrastructure may cause intense suffering and put patients at unnecessary risk.
At this conference I learned that emotional trauma can alter the brain’s processing of many sensory stimuli, which may then lead to global pain syndromes and emotional distress that is additively disabling. Many patients are receiving anxiolytic benefit from opioids and are struggling with high levels of anxiety and inner turmoil due to past traumas. These patients need trauma therapy, yet many primary care physicians aren’t sure how to define that, nor do they know who provides that in their area.
Communities often have licensed professional counselors and other behavioral health specialists who can provide some of these treatments. In the cover story of this edition of Texas Family Physician, you will find information on how to locate a variety of behavioral health specialists in your area with training to provide therapies most effective for treating post-traumatic stress disorder and anxiety, and who can assist in teaching patients coping strategies.
While many primary care physicians would prefer to refer these patients to addiction specialists, often this is not a practical reality for physicians practicing in smaller cities or rural areas. The lack of reliable patient transportation can also make referral unobtainable. In most areas of Texas, primary care physicians will need to continue being the medication prescriber, and additional educational tools are needed to support physician practices. One such resource is Project ECHO, which provides free education via a teleconferencing platform that primary care clinics can access from their own offices. Project ECHO has educational modules about addiction and pain management.
Studies have shown that addiction management with buprenorphine can lead to fewer overdose deaths, fewer ER visits, less crime, and less pregnancy complications, yet most primary care physicians are not comfortable prescribing this. Project ECHO also has a module on buprenorphine management, which can serve as a free educational support group for any physician prescribing this medication.
Naloxone has been shown to be a life-saving drug during opiate overdose situations, yet many primary care physicians are not prescribing this to patients who are at higher than average risk.
The state of Texas has mandated that Medicaid managed care programs in Texas have 25 percent of their total payments in 2018 associated with a value-based arrangement. It is possible that some insurers may be willing to pay up-front in value-based payment arrangements to enable physicians to invest in pain management infrastructure. Superior Health Plan is exploring that opportunity with Texas Medicaid now.
In the fee-for-service arrangement responsible for most primary care payments, there is an option to provide enhanced visits in a group visit arrangement. It is well established that alternative therapies such as yoga, tai chi, aquatic exercise, acupuncture, biofeedback, and mindfulness treatments are helpful in some patients with chronic pain, yet these treatments are not covered by insurance and may not be available in the patient’s community.
At the opioid conference, I learned about a progressive practice in Austin that has leveraged the power of group visits using the fee-for-service payment model to provide alternative therapies to their patients with chronic pain. The group visit, where several patients come together at one time, provides limited acupuncture treatments, quiet time, support group strategies, pain education, and low-impact exercise such as yoga or tai chi. Guest instructors and exercise experts are invited and the cost is supported by the billing of CPT codes for each patient by the supervising provider.
The fact that emotional trauma can cause physical pain is not a new problem. Psalm 38, written at about 1000 BC, helps to convey this:
“…my whole body is sick
because of my sins.
My guilt overwhelms me—
it is a burden too heavy to bear.
My wounds fester and stink
because of my foolish sins.
I am bent over and racked with pain.
All day long I walk around
filled with grief.
A raging fever burns within me,
and my health is broken.
I am exhausted
and completely crushed.
My groans come
from an anguished heart.”
Psalm 38: 3b-8
Many chronic pain patients tell me their “whole body hurts,” they are “racked with pain,” and “exhausted.” The primary source in some of our chronic pain patients is not a physical disease, but rather an “anguished heart.” Physicians are called to alleviate suffering, be that emotional or physical. Let us not cast these patients away because they are difficult to treat, nor chastise good doctors who are facing impossible challenges due to the lack of supportive infrastructure. It is time to work together to create real solutions for these patients.