Powerful DSUVIA Painkiller- Effective or Ripe for Abuse?

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The controversial DSUVIA painkiller is poised to upend the opiate market. Reportedly, 500 times more potent than morphine, DSUVIA is formulated to dissolve instantly, allowing it to act more quickly than other opioids. It was recently approved by the FDA despite reservations.

Acelrx, the company behind DSUVIA, believes that this drug represents an “important non-invasive acute pain management option.” Others are somewhat skeptical of the new drug.

“I find it truly surprising that in the midst of this nation-wide opioid problem, a new product is being considered for release that appears to be the ideal formulation for abuse of a very high potency narcotic with very little obvious clinical indication,” said Christopher Creighton, M.D., Physician Partners of America pain specialist in Richardson, Texas. He weighed in a few days before the FDA’s decision on DSUVIA.

Last year, the FDA rejected the drug’s approval. There were concerns that the drug could be administered improperly if it wound up in the wrong hands. This year guidelines have been included that require the drug to be administered only by trained healthcare professionals.

In the midst of the current opioid epidemic, lawmakers have serious concerns about the potential for misuse. Sen. Edward Markey (D-Mass.) believes that the FDA’s consideration of this new drug “makes no sense.” In a statement, Markey noted, “Even in the midst of the worst drug crisis our nation has ever seen, the FDA once again is going out of its way to approve a new super-charged painkiller that would only worsen the opioid epidemic.”

Pain management expert  and Chief Medical Officer with Physician Partners of America Abraham Rivera, M.D. echoes these concerns. He points out that DSUVIA is not a new drug. “It’s actually an oral formulation of Sufentanil. This drug was invented in the late 1950’s… It’s a ‘cousin’ drug to Fentanyl, Alfentanyl, Remifentanil, Carfentanyl, and a few others.”

When asked about the effectiveness of the drug as a pain management treatment, Rivera readily admits that it is extremely potent. However, he goes on to say, “In my opinion, it brings very little to the armamentarium of a pain management practitioner. It has a serious potential for abuse and misuse.”

Physician Partners of America has long focused on interventional pain management techniques that do not rely on opioids as a primary course of treatment.

Like Senator Edward Markey and others in the healthcare and political arenas who have seen firsthand the devastating effects opioid addiction has had on the community, Drs. Creighton and Rivera worry that people who want to abuse DSUVIA painkiller will find creative ways to accomplish their goals — regardless of the safety precautions the medical community or pharmaceutical companies put in place.

This is especially worrisome considering the potency of the drug. Dr. Rivera states: “This particular drug packs such a punch that I am afraid the recreational street chemists will get their numbers wrong and write their mistakes on gravestones.”

Non-oral forms of the DSUVIA painkiller are already being used in the operating room as an adjuvant anesthetic. In this setting, it has excellent cardiovascular stability at high doses, Rivera says.

He summed up his feelings about introducing DSUVIA to the market like this: “Taking this drug out of the operating room and putting it in an oral formulation reminds me of the making of small nuclear weapons. In times of conflict, some people thought that it would be a good idea. Drop a small nuke here and there and save money on bullets. Good thing somebody disagreed.”

 

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Proposed Federal Opioid Law Aims to Tackle Growing Problem

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Bill Has Rare Bipartisan Support –

Update: President Trump signed the bill into law Oct. 24.

A proposed federal opioid law addressing the opioid crisis would increase access to treatment for addiction, open the door for non-opioid therapy, and limit over prescription of narcotic painkillers.

On October 3, in a rare show of bipartisanship, Congress passed the SUPPORT for Patients and Communities Act. The bill was approved by a vote of 98 to 1 in the Senate and 393 to 8 in the House of Representatives. The opioid legislation is expected to be signed into law by President Donald Trump and take effect Jan. 1.

With an opioid-related death toll at 700,000 and rising since the 1990s, Physician Partners of America (PPOA) applauds the proposed federal opioid law.

“Pain management specialists are at the forefront of combating this national problem,” said Abraham Rivera, M.D., chief medical officer of Physician Partners of America. “We embrace the actions of congress and will incorporate the resources the law provide for the welfare of our patients.”

The company stresses its interventional pain management approach, which treats the root of  pain problems, over masking symptoms with opioid medication.

The far-reaching legislation package is aimed at changing the way the United States approaches the addiction issue. Provisions include:

  • Creating a grant program for opioid recovery centers to address treatment and recovery
  • Allowing more health care practitioners to prescribe opioid addiction medications
  • Expanding the availability of naloxone, a medication that reverses overdoses, to first responders
  • Allowing government agencies to pursue addition and pain research projects
  • Educating a wider group of health care providers about best practices in pain management

The new federal opioid law aims to limit overprescription of opioid painkillers to Medicare and Medicaid recipients, and expands access to addiction treatment within those programs

“The Centers for Medicare & Medicaid Services’ reimbursement for common pain management procedures are also going up because of this,” said Luis Nieves, M.D. PPOA’s Hurst, Texas pain management specialist.  “Hopefully private insurance will follow and improve access for all patients.”

 

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Arachnoiditis Pain Causes and Treatment

PPOA Treatment Can Ease Back Pain from This Rare Disorder

Arachnoiditis has nothing to do with spiders, but its symptoms can be pretty scary. Difficult to diagnose and difficult to treat, this rare nerve inflammation can trigger excruciating lower back and leg pain. It is a progressive and debilitating disorder that can cause some people to become bedridden and unable to work.

What is Arachnoiditis?

The condition affects only about 11,000 people a year, according to the National Organization for Rare Disorders.  It is almost always caused by a medical procedure.

It starts in the web-like arachnoid membrane that protects the spine and brain. When the membrane becomes inflamed, it can cause the nerves to fuse together. This causes them to malfunction. The resulting scar tissue can press against the nerve roots that exit the spine, causing severe pain.

Arachnoiditis pain usually affects the lower back and legs and causes a variety of sensations.

  • Tingling or “creepy-crawly” feelings on the skin
  • Muscle cramps, twitching and spasms
  • Shooting, “electric shock” pain
  • Bowel, bladder and sexual problems

“It causes a number of symptoms and they can vary in the same individual,” said Dr. Abraham Rivera, chief medical officer of Physician Partners of America.

What Causes Arachnoiditis?

This condition has many causes. The majority are related to contaminants that accidentally get into the dura – the fluid surrounding the spinal column – during certain medical procedures like epidurals and spinal taps.  These contaminants include preservatives or impurities. Long ago, oil-based chemicals used in contrast dye tests, like myelograms, were blamed for some cases of arachnoiditis.

How is Arachnoiditis Diagnosed?

This disorder is so uncommon that most doctors rarely see it in their practices, making detection difficult. Fortunately, Physician Partners of America Pain Relief Group has the expertise to identify it and attempt to treat the pain.

The most helpful diagnostic tests are MRIs (magnetic resonance imaging) and CAT scans (computerized axial tomography). Another test, an EMG (electromyogram), uses electrical impulses to determine the extent of damage to nerve roots. PPOA specialists can perform this test.

What is the Best Arachnoiditis Treatment?

Unfortunately, there is no cure for this condition, but Physician Partners of America offers the hope of relief from arachnoiditis pain.   “One common treatment is oral pain medication, but it doesn’t tend to work well,” says Dr. Rivera. “The pain can be managed for some people with a spinal cord stimulator.”

Spinal cord stimulators are minimally implantable devices that send electrical signals to targeted areas of the spinal cord to treat specific pain conditions. It is a minimally invasive procedure that PPOA physicians perform routinely.

Stems cell therapy for arachnoiditis is only in the experimental stage and has not yet been proven helpful.

“We are keeping our eye on the latest research to treat this debilitating condition,” says Dr. Rivera. “Not every current treatment works for everyone, but we make every effort to treat the pain and help sufferers lead a more normal life.”

 

 

 

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Physician Partners of America Honors Pain Awareness Month

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Sharing Stories of Pain and Hope

“Everything I enjoyed caused me intense pain. It affects every aspect of your life,” says J.B., 49, one of our Texas pain patients. “Not until you get treatment do you realize you can live with less pain.”

More than 12,000 patients walk through our doors each month seeking pain relief treatment. J.B.’s is one of the many personal reflections we will share during September, which is Pain Awareness Month.

According to the American Chronic Pain Association, which organizes the annual event, about one in three people lives with intractable pain. Helping them manage and overcome it has been the mission at Physician Partners of America since 2013. We hear stories daily of people like J.B., who live with all types of chronic pain: degenerated discs, spinal stenosis, migraine, fibromyalgia, arthritis, cancer pain and diabetic neuropathy, among others. It is our goal to help each patient seek a path of pain relief.

How Many People Live with Chronic Pain?

During Pain Awareness Month, we are reminded of the startling numbers related to chronic pain:

  • It is the number one cause of adult disability in the U.S.
  • It affects 50 million Americans
  • It costs $100 billion per year in lost workdays, medical expenses and other benefit costs.
  • It is a social issue. As you will see from the stories we will present to you each day on social media, unmanaged chronic pain is isolating. It causes people to withdraw from friends, family and communities.

Interventional and Integrative Pain Management Approaches

Physician Partners of America practices interventional pain management. That means getting to the root cause of the pain and treating it as its source. Some types of pain can be relieved to a degree and others can be eliminated. Our pain management doctors work with our orthopedics and laser spine divisions to find the best course of treatment for each patient.

What about Opioids for Pain Treatment?

As Pain Awareness Month illustrates, the debate over opioids for pain continues to heat up. Nearly 2 million Americans have a disorder related to prescription painkillers, according to the National Survey on Drug Use and Health.

It’s important to remember that the opioid crisis stems from treatment of acute pain, the type that lasts less than three weeks. Historically, opioid medications were prescribed for short-term pain because they are effective.

“Opioids are very seductive drugs, but they work. You give opioids to somebody in pain and believe me, the pain goes away, but it only works for so long,” PPOA Chief Medical Officer Abraham Rivera, M.D., told a recent televised opioid town hall. “In the acute setting, they are phenomenal drugs. After that, the patient gets hooked on them. They’re extremely addictive.”

Strict prescription limits are now in place in many states as a result.

Physician Partners of America has long recognized the dangers of opioid addiction and uses effective options to treat the root cause of the pain versus masking it. They include:

  • Interventional pain management as a preferred treatment
  • Opioid antidotes prescribed along with every opioid-based prescription.
  • Medication management
  • Intraoperative neuromonitoring to avoid accidental nerve damage during surgery
  • Drug-genes testing to determine the right medication for each patient

New Prescribing Laws

Restrictive new laws are aimed at people with acute pain. PPOA’s pain management doctors specialize in chronic pain, which lasts more than three to six weeks. We do write prescriptions for opioid medications in select cases. Usually, these are patients who have been taking these medications for years just to function normally. However, we manage these types of prescriptions carefully.

PPOA doctors believe in reducing dosages wherever possible. PPOA founder Rodolfo Gari, M.D, MBA, recalls many successes. “I’ve had some really gratifying stories over the past 30 years – patients who come in with mega-doses of opioids and you wonder how they walked into your office.”

Pain Awareness Month is Just the Beginning

Neurostimulators and minimally invasive laser spine procedures are just some of the cutting-edge treatments PPOA uses in severe pain cases, along with nerve blocks, injections and minimally invasive laser spine procedures.

While we have seen many success stories, there is still a long way to go. The Food and Drug Administration held the first of several planned hearings with chronic pain patients in July. The agency aims to shape new guidelines to address concerns that some feel have been muted in addressing the opioid crisis.

PPOA will be watching with interest. We will keep key issues top of mind through Pain Awareness Month. We will continue to find a balance between patient safety and humane guidelines, practice interventional treatments, and wage a battle against chronic pain, one patient at a time.

 

 

 

 

 

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PPOA Offers New Spinal Stenosis Treatment

Vertiflex procedure is minimally invasive and reversible

A new spinal stenosis treatment is allowing people to walk without pain for the first time in years – and without relying on opioids. Physician Partners of America now offers this minimally invasive procedure, known as the Superion Indirect Compression System, at its Texas Pain Relief Group and Florida Pain Relief Group locations.

This spinal stenosis treatment has even helped some patients leave their wheelchairs behind. That’s what recently happened for a patient of Christopher Creighton, M.D., Physician Partners of America’s pain management specialist in Richardson, Texas.  “It was truly remarkable,” Dr. Creighton says. “He came in in a wheelchair and walked out of the surgery center 100 percent pain-free.” Another patient who had hobbled for years had the same result.

Dr. Creighton calls the unique system “remarkable. I’ve never seen anything like it in my 26 years in practice.”

How does this spinal implant work?

Manufactured by Vertiflex, it is a one-inch titanium implant that slightly spreads the vertebrae, relieving pinched nerves. The implant “decompresses,” or widens, the spot that is compressing the nerve.  Once it is in place, the surgeon releases two “arms” on either side of the device to keep it secure.

The procedure takes about 30 minutes, causes little bleeding, and does not involve removal of bones or tissue. It is also completely reversible if the patient chooses a different procedure later on.

What is spinal stenosis?

Most often seen with age and wear and tear, stenosis is a narrowing of the spinal canal. It is usually associated with the lumbar, or lower, spine. The narrowing process squeezes on nerve roots that exit the spine, causing pain.

Spinal stenosis symptoms

The most common way to tell if a patient needs lumbar spinal stenosis treatment is when bending over feels better than standing straight. The bending motion opens up the space between the vertebrae, temporarily relieving the nerve compression.

What is spinal decompression?

Since it’s not comfortable to live life bent over, decompression surgery might be an answer. “Surgery,” in the case of Physician Partners of America, is always minimally invasive. That means an incisions that is one inch or less. While there are several ways to treat painful back conditions, Vertiflex shows much promise.

“It’s much faster to perform, it has less operative risk, and the results are immediate,” Dr. Creighton says.

Vertiflex procedure – an alternative to spinal fusion

This decompression device can also help people whose spines have become unstable from disc degeneration. This process releases proteins in spinal fluid, which can irritate sciatic nerves. A traditional treatment is spinal fusion, in which two or more vertebrae are permanently joined together with hardware into a single structure. The goal is to stop movement between the two bones and prevent back pain.

Fusion usually has a three- to six-month recovery time. Compare that with the days of weeks of recovery after a Vertiflex implant.

Patients in a clinical trial reported 73 percent improvement in back function after two years and 81 percent improvement after five years. Overall patient satisfaction with the implant stood at 90 percent after five years.

Ask your PPOA physician about the Vertiflex procedure as a disc degeneration and spinal stenosis treatment.

 

 

 

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Cut Out These 5 Foods to Reduce Your Pain Now – the Inflammation Diet

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What is the inflammation diet?

It’s a possible way to calm your body’s response to pain and stress: the inflammation diet. Eating the right foods may fight inflammation, a key source of joint and nerve pain, while eating the wrong foods may make any inflammation in your body worse. Chronic (long-term) inflammation can lead to many conditions: pain, degenerative diseases, high blood pressure, heart disease, type 2 diabetes, hardening of the arteries (atherosclerosis) and cancer.

Foods That Cause Inflammation Pain

A recent Harvard Health study links certain foods to inflammation. They include:

1. Refined carbohydrates. We’re talking about white bread, pastries, doughnuts, cakes, and the like.

2. Fried foods. French fries, potato chips, and fried chicken would fall into this category as well.

3. Sugar.  The American Journal of Clinical Nutrition warns that processed sugars trigger your body to release inflammatory messengers called cytokines.

4. Red meat. This includes steaks, burgers, and processed meats like hotdogs and sausage.

5. Shortening. Excessive amounts of lard, trans fats, cooking shortening and margarine may also trigger an inflammation response.

No surprises here. These foods have long been thought of as unhealthy when eaten in excess. They have been linked to diseases like type-2 diabetes, heart disease and overweight. Inflammation can cause these diseases to develop and stay. Some, like arthritis and degenerative disc disease, can lead you to see a pain management doctor.


Inflammation Diet Foods

On the other side of the coin, there are foods and beverages that have been linked to calming or preventing inflammation. They include:

  • Fruits like blueberries, strawberries, oranges and cherries
  • Leafy green vegetables like spinach, collards and kale
  • Tomatoes
  • Nuts like walnuts and almonds
  • Fatty fish like tuna, salmon, mackerel and sardines
  • Olive oil

Not surprisingly, the foods on this list are considered healthy. There are others, too. Substances in coffee and the spice turmeric are also grabbing headlines for their supposed anti-inflammatory properties.

What Is Inflammation?

To see how a healthy diet helps, you need to understand how inflammation affects your body. Inflammation is part of the immune response to foreign invaders like chemicals, microbes and allergens. It is your body’s self-protection, sending out white blood cells and other substances. Without the inflammation process, cuts and bruises would never heal.

Inflammation goes from being your friend to being your enemy when it continues day in and day out, even when there is no foreign invader threatening your body. It is this chronic inflammation that has been linked to pain and disease. Your doctor can order blood tests like CRP (C-reactive protein) and interleukin-6 to measure the level of inflammation responses in your body, and then recommend a course of treatment.

How to Create an Inflammation Diet Plan

Diet does appear to play a role in keeping inflammation in check. Certain diet plans, such as the Mediterranean diet, have moved into the spotlight for their positive effect on health. This diet is heavy on fish, fresh fruit and vegetables, healthy oils and nuts.

“There’s good evidence that a Mediterranean diet reduces inflammation and the many diseases it causes,” said Ronald Stern, M.D., principal pain management physician at Physician Partners of America in Melbourne, Fla., and the author of Meals, Movement and Meditation – Using Science, Not Myth, for Healthfulness.

Dr. Stern is adamant about separating fact from fad – his book cites more than 400 sources – and says it is hard to find conclusive studies showing that certain foods reduce the body’s inflammatory responses.

One possible reason: most food studies are not done on humans; they are done on animals or cells in a lab, nutritionist Karen Collins points out. Studies so far show “any potentially anti-inflammatory compounds … are broken down to smaller, more easily absorbed compounds before they leave the digestive tract and circulate in the blood. So testing the large compound is not testing what is actually reaching body cells,” she writes in her blog.

And there is no hard evidence that eating more of the right helpful substances in food will stop inflammation, Collins says.

Still, there is no question that good food choices, a healthy lifestyle and good medical care are compatible with lower inflammation, and this can help ease any pain you are feeling. In other words, it can put you on the right – rather than the wrong – path to a higher quality of life.

 

 

 

 

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What Should I Do for Knee Pain After Surgery?

New treatment relieves knee pain after surgery

A new, minimally invasive treatment shows promise for relieving knee pain after surgery, especially total knee replacement. Michael Lupi, D.O., of Physician Partners of America Pain Relief Group – Jacksonville, Fla., is pioneering this procedure, called a peripheral nerve stimulator of the genicular (knee) nerve.

Dr. Lupi recently became the first doctor in the country to perform this surgery as a treatment for pain after a total knee replacement.

“This treatment blocks one or all three of the branches of the genicular nerve in the knee, leading to long-term pain relief,” Dr. Lupi said. “Peripheral nerve stimulation is a promising treatment of chronic knee pain that can’t be controlled by replacing the knee joint.”

What Leads ot Knee Pain in the First Place? 

Arthritis of the knee, also known as osteoarthritis, is a major reason for replacing the knee joint. If often comes with age, when people lose cartilage; but there are other reasons a person might develop knee problems that may require surgery.

  • Excess weight puts extra pressure on knees joints. Every pound of weight a person gains leads to three or four pounds of extra pressure on their knees.
    Genetics makes some people more likely to develop knee problems. Others inherit abnormally shaped bones around this joint.
  • Women, especially those over 55, are more likely to develop osteoarthritis of the knee than are men.
  • Repetitive stress injuries caused by squatting, kneeling or lifting heavy objects increases the chance of developing knee joint problems.
  • Sports can be a two-edged sword when discussing knees issues. “On the one hand, being physically active can strengthen your knee joints and reduce the risk of osteoarthritis,” said Dr. Lupi. “But with that comes a risk for athletes like long distance runners, soccer players, or tennis players. They have a higher risk of osteoarthritis, especially if they injure their knee.”
  • Other illnesses can increase your chances of knee osteoarthritis, such as rheumatoid arthritis, metabolic disorders and hormone imbalances.

Pain is the number one symptom of knee arthritis. The pain is more intense when you are active, but it subsides with rest. Swelling and a warm sensation in the joint are other symptoms. Stiffness, especially after sitting for a while or after waking up, is another common symptom.

How Does a Doctor Diagnose Arthritis of the Knee?

A physical exam by your doctor is the first step in diagnosing osteoarthritis. Your physician will review your medical history and note symptoms. He or she is interested in seeing what makes your pain worse and what relieves it.

Your doctor will also ask about your family history to find out if other members of your family have had this form of arthritis. your doctor may order some tests, including:

X-rays – These will show cartilage damage, bone damage, as well as bone spurs.

MRI scans – Magnetic resonance imaging scans may give your physician a clearer view of the joint than x-rays. This is especially true when joint tissues are damaged.

Additional testing – Your doctor may use blood tests to rule out other conditions that may be the source of your pain. These include immune disorders like rheumatoid arthritis.

Traditional Treatments for Arthritis of the Knee

Losing weight, even just a little, can dramatically reduce knee pain from osteoarthritis. Adding exercise to strengthen the muscles around the knee and stretching exercises to make the joint more flexible and stable will likely result in reducing pain.

Pain relievers and anti-inflammatory drugs such as Tylenol, Advil, Motrin, ibuprofen or Aleve may provide temporary relief. Over-the-counter pain medication should not be taken for more than ten days without checking with your doctor. If you take it longer, your chances of developing negative side effects increases.

If over-the-counter medication does not ease your knee pain, your doctor may provide prescription pain medication or anti-inflammatory medication. Injections including corticosteroids or hyaluronic acid can reduce inflammation and restore lubrication to the knee.

Alternative therapies like acupuncture or supplements including glucosamine, chondroitin, or SAMe capsaicin may provide temporary pain relief.

Braces for post-knee replacement surgery are easy to get and come in two types. There are “unloader” braces that are designed to remove weight from the side of the knee that is affected by arthritis. “Support” braces are designed to support the entire knee.

Physical therapy can show you how to increase the strength and flexibility of your knee joint. Occupational therapy will teach you how to go through your daily activities at work or at home with less pain.

Total Knee Replacement Surgery

When common treatments do not work, a total knee replacement surgery may be the best choice. The purpose of the knee replacement is to decrease pain and increase function. But what if pain continues after the total knee replacement?

Opioid painkillers are the first thing many patients, and some doctors, reach for to control knee pain after surgery. But now we know how addictive they are. Dr. Lupi, who has long campaigned against opioid abuse, has embraced the peripheral nerve stimulation (PNS) in addition to other minimally invasive procedures to control pain.

Peripheral Nerve Stimulation Helps Knee Pain After Surgery

To see if you’re a candidate for peripheral nerve stimulation, you will first get a temporary nerve block to decide if this controls knee pain after surgery. If the block reduces your pain by at least 70 percent, you could be a candidate for a PNS trial. This trial involves thin wires with electrodes attached to the treatment area on the outside. it usually lasts between three and seven days.

If the trial gives you 70 percent or more relief from your pain, you can consider a permanent stimulator implant. This small device produces an electrical stimulation that blunts the pain at the genicular nerve. You control the level with a hand-held remote.

“This is an exciting development in pain medicine,” said Dr. Lupi. “And I encourage knee replacement patients still experiencing pain to get an evaluation.”

 

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PPOA Participates in Live Opioid Crisis Town Hall

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PPOA leaders represent pain physicians on panel

The scope of the opioid epidemic and new solutions took center stage at a live “Opioid Crisis Town Hall” special, sponsored by cable stations Spectrum Bay News 9 and Spectrum News 13 in Bradenton, Fla. on May 22.

Physician Partners of America (PPOA) founder Rodolfo Gari, M.D., MBA, and Chief Medical Officer Abraham Rivera, M.D., were the only pain management physicians chosen to participate on the panel. It drew more than 700,000 viewers.

Dr. Rivera explained how opioids have been used in one form or another for thousands of years, and people must not forget that they’re used because they work.

“In the acute [pain] setting, they are phenomenal drugs. After that, the patient gets hooked on them. They’re extremely addictive,” he told the audience.

Acute pain is discomfort lasting no more than 3 to 6 months, and it is usually related directly to soft tissue damage such as a sprain or surgery.

Also on hand were an emergency room professor, local law enforcement leaders, an advocacy group representative, and State Rep. Jim Boyd (R-District 71). A live audience was invited to listen in and ask questions.

The one-hour Opioid Crisis Town Hall was moderated by Bay News 9 anchor Veronica Cintron, and covered a wide range of topics related to new Florida opioid legislation. As of July 1, the law puts a three-day limit on most opioid prescriptions for acute pain. This does not apply to all patients, including those who live with certain chronic pain conditions.

The new Florida law funds $65 million for the treatment of addiction and includes providing the overdose-reversal drug Naloxone to first responders. While not providing as much funding as the bill’s champions had hoped, stakeholders applaud the policy direction.

Preventing opioid addiction through intervention

Drs. Gari and Rivera addressed the need to stop opioid addiction from happening. As interventional pain management specialists, Physician Partners of America providers get to the root of pain and treat it through various pain blocking procedures and minimally invasive techniques. Opioids are not the preferred course of treatment, but each patient’s condition is handled on a case-by-case basis.

“One of the things we can do to help this epidemic is to markedly decrease the number of customers that go to these treatment centers,” Dr. Gari said. “We can help patients but it’s going to take physicians that are serious about this and understand there are a lot of options that patients can have other than opioids.”

First-hand stories of addiction played a prominent role in the town hall and a preceding documentary. One Bradenton woman told an emotional story of how a car accident resulted in her addiction to opioids. Now drug-free, she described how she innocently got hooked after a doctor gave her a large supply of an opioid painkiller.

Dr. Rivera, touting the benefits of interventional care, told the audience, “Had that girl seen a pain specialist three days after she had her accident, she would never have fallen victim to opiates.”

Addressing fake pain

Both Drs. Gari and Rivera acknowledged that one of the thornier problems faced by physicians in the opioid crisis is determining who is a legitimate pain patient and who is doctor-shopping or faking discomfort. Pain doctors report seeing more people who claim their meds were stolen to get a new prescription.

“When a patient comes to me and they tell me their medication gets stolen, I treat that with a high degree of skepticism …I ask them for a police report,” Rivera said.  In suspicious cases, he offers a three-day supply of painkillers, requires immediate and frequent follow-up urine tests, and asks such patients to show him their unused portion.

Responding to questions about victim-blaming, the doctors explained PPOA’s drug-tapering protocol for new patients who are opioid-dependent.

As Dr. Gari told the Opioid Crisis Town Hall audience, “We treat our patients like they’re a family and like they’re our kids …you’re going to treat your kids with what you think your kid needs. It may not be always what your kids want… it’s what he needs, but you have to have these conversations.”

Patients should see a pain specialist

Noting that many patients visit their primary care providers for pain conditions, Dr. Gari stressed the benefits of early treatment by a board-certified pain management specialist. “A primary care physician would not be prescribing chemotherapy for a cancer patient,” he said. “So I believe [pain management] needs to be done by specialists that only treat pain.”

State Rep. Boyd, who praised PPOA leadership for supporting funding efforts for the opioid issue, agreed. Turning to Drs. Gari and Rivera, he told the Opioid Crisis Town Hall audience, “These are the professionals that should be prescribing that.”

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For Some, Topical Medications Can Replace Opioids

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Doctors have known for years that topical pain medications – those applied to the skin – are effective for some pain patients. Recently, however, they were surprised to learn that those creams, patches and ointments are more helpful than previously thought.

In fact, half of patients taking oral opioids stopped them after trying topicals, a recent study shows. Another 30 percent were able to quit using all types of pain medications and switch to topical analgesics.

The study, published in Clinical Focus: Pain Management Fast Track, surprised even its authors. “As a clinician active in the pain world, I have seen it [discontinuation of opioids] but certainly not at this magnitude,” study leader Jeffrey Grudin, M.D., told Practical Pain Management. Grudin is director of pain management and palliative care at Englewood Hospital and Medical Center in New Jersey.

About the Topical Pain Medications Used

The study followed 121 chronic pain patients. After treatment with topical analgesics, 49 percent of those followed after three months and 56 percent of those followed up at six months said they had stopped using opioids altogether.

Another 31 percent followed up at three months, and 30 percent reporting at six months, said they were not taking any more pain medications. This included nonsteroidal anti-inflammatory drugs (NSAIDS), which target the inflammation   that causes most neck and back pain.

The patients who took part in the study suffered moderate symptoms of neuropathy, arthritis, radiculopathy, myofascial musculoskeletal or tendonitis pain.

The Most Effective Topical Pain Medications

The topical analgesics used in the study included diclofenac, ketoprofen and flubiprofen. Other topical pain medications readily available through pharmacies are also shown to be effective. They include baclofen, ketamine (3-5%) and lidocaine (7-8%).

More Research Needed

It is clear that more research needs to be done. The study was small, and 67 of 121 study participants dropped out before the six month follow-up. Still, the study shows this is one opioid alternative that holds promise for people suffering from chronic pain.

“Topical analgesics are effective for a variety of types of pain,” Dr. Grudin, the study leader told Practical Pain Management. “Our study supports the fact that we can eliminate opioid use in a certain percentage of patients with chronic pain conditions.”

 

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Prescription Opioid Summit Asks Doctors to be Proactive  

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Peer-approved prescriptions, drug-gene testing and electronic prescribing may be the wave of the future in the war on prescription opioid abuse. Those were some of the key takeaways for more than 60 physicians from around Florida at a recent Opioid Summit. Dr. Abraham Rivera, chief medical officer of Physician Partners of America, served as presenter of the April 28 event in his role as board member of the Florida Academy of Pain Medicine (FAPM).

“The legal landscape is changing, and we need to change the way we prescribe,” said Dr. Rivera, an interventional pain management specialist and anesthesiologist.

The Opioid Summit seeks to define the scope of the growing abuse problem and ways to solve it.  Among the speakers was U.S. Rep. Gus Bilirakis, R-Florida, as well as representatives from law enforcement and the legal field. The presentations focused on responsible prescribing, transparency and alternative treatments.

Avoiding Prescription Opioid Abuse 

In the absence of uniform prescribing laws and indications, opioid painkillers should be used as a means to an end, not as an end by itself. Drug tapering and detox protocols should be used routinely and all prescriptions should follow a specific diagnosis, with no off-label prescribing. Sustained release opiates should be used no more often than twice a day. Short-acting opiates are used no more often than four times daily. Electronic prescriptions are encouraged for a variety of reasons: they provide solid documentation from the beginning of treatment and they do not get lost. There is also less potential for abuse, diversion and tampering.

Finally, the summit proposed that opioid prescription records should be monitored by a physician’s peers for review. “Accountability and transparency are key,” Rivera said.

Changes in Opioid Laws

Like many states, Florida is clamping down on prescription protocols. A new law that goes into effect July 1 limits such prescriptions to three days – seven in cases deemed medically necessary. The laws address people who suffer from acute pain, but more discussion is needed to address the needs of chronic pain patients. Those are defined as people who experience pain for more than 12 weeks.

Dr. Rivera’s take: “Every case is different, but in general, a one-month supply is reasonable for chronic patients.”

Interventional Pain Management

To Physician Partners of America, the answer lies in interventional pain management. This subspecialty of pain medicine seeks to pinpoint and treat the pain at its source without relying on prescription opioid medication.

Interventional treatment includes:

  • Epidural injections
  • Facet blocks
  • Radiofrequency ablation
  • Nerve blocks
  • Corrective surgery
  • Intrathecal pumps
  • Neurostimulation

Dr. Rivera also recommended that physicians explore alternative treatments such as Traditional Chinese Medicine, acupuncture, chiropractic and massage.

Monitoring Pain Patients

Physician Partners of America recommends performing urine drug tests (UDTs) on pain patients, starting before the first prescription is written and then when indicated. The frequency varies according to individual patient risk.

In addition, prescriptions should not be copied or given to the patients at office visits. The system is not foolproof, however. Roadblocks include lack of communication between states and the Veterans Administration, and the fact that some states do not have this system.

Legislating Opioid Prescriptions 

Recommendations include using prescription drug monitoring programs (PDMS) for every prescription. The summit’s presenters also recommended fuller implementation of the National All Schedules Prescription Electronic Reporting Act (NASPER). Enacted in 2005, this U.S. Department of Health and Human Services program gives grants to states to start or enhance prescription drug monitoring programs.

Rep. Bilirakis discussed the intent of Congress to fund programs to help with the opioid crisis across the nation. He noted that the House has passed legislation to address this issue, but the Senate has yet to bring it up for discussion.

Is Naloxone the Answer?

For those patients who are still opioid users, the summit presented an innovative approach: prescribing a companion prescription of the opioid antidote Naloxone to prevent accidental overdose. The U.S. Surgeon General recently endorsed this idea. Since its inception, PPOA has encouraged its physicians to prescribe an antidote to every patient who is prescribed an opiate in excess of 50 mg. per day of morphine equivalents.

Alternative Pain Therapies

Interventional pain management should be considered as a first course of treatment for select pain patients as an alternative to a prescription opioid. It gets to the root of the problem and provides direct relief. Interventional treatment includes:

  • Epidural injections
  • Facet blocks
  • Radiofrequency ablation
  • Nerve blocks
  • Corrective surgery
  • Intrathecal pumps
  • Neurostimulation

Intraoperative Neuromonitoring (IONM)

Intraoperative neuromonitoring is also being used to reduce pain following surgery and, therefore, the use of narcotic painkillers post-operatively. IONM is designed to minimize neurological damage during surgery. It identifies changes in brain, spinal cord, and peripheral nerve function prior to accidental, irreversible damage.

Pharmacogenomics

Medication efficacy is determined in part by genetics. What works for one person is likely to be different form another. Drug-genes testing is routine at PPOA, ensuring that the safest doses of the right medications are administered.

The ideas presented at the summit are likely to spark further discussion at the FAPM’s annual conference in July at the Orlando Grand Hyatt. And while approaches differ, pain management physicians are changing their way of thinking about a prescription opioid as a first course of treatment.

“Opiates should be used as a means to an end,” Dr. Rivera said, “and not as an end by itself.”

 

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