Make Pain a Thing of the Past – Prescription opioid abuse – Physician Partners of America

Tag Archive for: Prescription opioid abuse

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.






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.


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.”


Opioid overdoses are now the leading cause of death in people under age 50, killing about 64,000 Americans in 2016.

While short on specifics, President Donald Trump addressed this “national emergency” in his first State of the Union address, saying, in part, “My administration is committed to fighting the drug epidemic and helping get treatment for those in need. The struggle will be long and difficult — but, as Americans always do, we will prevail.”

What pain management physicians must do to treat chronic pain is to retrain patients’ – and even practitioners’ – thinking that narcotic painkillers are the first course of action.

“To fight the opioid epidemic, you need to dissuade people from using them in the first place,” said Abraham Rivera, M.D., chief medical officer for Physician Partners of America (PPOA). He will address this subject at the Florida Academy of Pain Medicine at an April 28 Opioid Update summit in Clearwater, Fla.

Interventional pain management, a core practice of PPOA, remains a little-discussed part of the solution. Rivera points out that not everyone in the healthcare community understands the meaning of that key word, interventional. “Our providers get to the root of the problem,” he said. “We don’t just mask the pain with medication. That is at the heart of what we do.”

Interventional pain management, as practiced by PPOA physicians, focuses on minimally invasive procedures such as nerve blocks, radiofrequency ablation, injections, spinal cord stimulators and pain pump implants to treat the pain at its source.

Laser-assisted Spine Surgery

PPOA recently launched laser-assisted, minimally invasive spine surgery. This outpatient procedure, reserved for cases that interventional techniques may not be able to address, are not like open-back surgeries of the past.

  • It requires incisions that are less than one inch long
  • Muscles surrounding the spine are gently spread with small dilating instruments instead of being cut and retracted
  • Narrow endoscopic instruments, guided by tiny video cameras that project magnified images onto a screen, further spare tissue trauma
  • Patients can get back to work or activities in days or a few weeks, not months

Physician Partners of America is actively adding spine specialists to its team, including James St. Louis, D.O., surgical founder of Laser Spine Institute in Tampa.

Cutting-edge Orthopedic Procedures

Orthopedics is another interventional aspect of PPOA’s medical services. Led by PPOA physicians Brian McGraw, D.O., and Chad Gorman, M.D. in Florida, our services help patients with trigger point injections and other minimally invasive procedures, PRP (platelet-rich plasma) therapy to aid in soft tissue recovery, and stem-cell regeneration.

Preventing Pain

Interventional pain management also seeks to lessen the likelihood of pain that traditionally requires oral medication. To this end, PPOA physicians routinely use intraoperative neuromonitoring, a real-time monitoring of the nervous system during surgical procedures. This offers nerve-damage protection to a degree that neither a physician nor fluoroscopy can detect with accuracy. The result is usually minimal pain and reduced risk of temporary or permanent nerve damage.

Another interventional tool is used at the clinical level: test can determine which medications are safe, unsafe or ineffective based on the individual patient’s genome.

“Cutting-edge technology, such as intraoperative neuromonitoring and drug genes testing, ensure patient safety and reduce pain,” said Dr. Rivera.

As word gets out about interventional methods of controlling and avoiding pain, the goal is for patients to ask for it – instead of opioids – by name, and for primary care physicians and specialists alike to refer patients to an interventional pain management specialist.

This lesser-known area of medicine is a key to solving the opioid crisis, and will, to use the president’s words, prevail.