Physician Patient

Archive for February 1st, 2018

Addressing the Opioid Death Crisis

Thursday, February 1st, 2018

The hospital emergency department (ED) is not the proper setting to do an in depth assessment of a patient’s future needs and provision of ongoing medical or psychiatric or addictions care. This is particularly true for assessing the diagnosis, impact and treatment of chronic pain conditions. And the ED is certainly not the preferred venue for establishing a trusting doctor-patient relationship; at best, it may be a start. But it takes two to tango. And what is the next step? Emergency Medicine in the Age of Managed Care has, for various reasons, become the default “provider” for many too many medical assessments. The ED doc is in the necessary business of triage.

EHRs are no panacea. Calls for alerts and stops on the electronic chart may be OK, but they often lead to CYA (defensive medicine) and patient abandonment. Limiting ER dispensing to ten opioid pills might help, but the real question is what happens to the patient next. Followup? Stigmatizing patients and doctors is not the answer. Crying wolf and putting Prince on a plane? Yes, patients do have rights, I know. But as all parents know, sometimes intervention is necessary.

The Minnesota Prescription Monitoring Program is a valuable tool. Its use should be enthusiastically promoted. In my addictions practice I’d use it as a tool to put data on the table and discuss plans with the patient.  https://mnpmp-ph.hidinc.com/mnlogappl/bdmnpdmqlog/pmqhome.html. PMP registry is a recent requirement for Minnesota medical  licensure. This is good.

Opioid deaths in Minnesota continue to rise. http://www.startribune.com/minnesota-opioid-deaths-rise-despite-attention-intervention/424836053/  Obviously this bad situation has both supply and demand dimensions. But physicians and pharmacists are being blamed inordinately. Drug advertising is ubiquitous. And of course pot (both medicinal and recreational) is viewed in the media as a a different matter. We need a lot of education and common sense. And patients and families are key in endorsing (or not) all drug using behaviors.

Two Minnesota experts on effective primary care relationships with patients understand its value for pain management, and also the limited ability of the ED in reversing the current “opioid epidemic.”

Dr. Scott Jensen (http://www.catalystmedicalclinic.com/relationship-matters-the-foundation-of-medical-care-is-fracturing/ ) and Dr. Wayne Liebhard are two physician authorities on the marginalization of Minnesota primary care, and they authoritatively write about it. They wear both the hat of a primary care physician who espouses professional relationships and alliances with his/her patients and also (in recent years) emergency room physician. Many well trained primary care doctors have become ED doctors due in large part to the lack of administrative support and payment for relationship-based primary care services in Minnesota’s managed care clinic and health insurance systems. Dr. Wayne Liebhard wrote  The Vortex Effecthttps://www.amazon.com/Vortex-Effect-Wayne-Liebhard-M-D/dp/1634134885 and Elephants in the Examining Room https://www.amazon.com/Elephants-Exam-Room-Things-Todays/dp/0979846757/ref=sr_1_3?ie=UTF8&qid=1516919130&sr=8-3&keywords=elephant+in+the+exam+room

Below are two articles (perhaps) linking opioid prescriptions (for pain) to Medicaid funding. The argument goes that economically challenged patients on Medicaid have a heightened incentive to sell their prescription opioids on the street. And criminal drug dealers entice them to do so. yet, rich, white suburbanites are dying at high rates. See:

https://www.hsgac.senate.gov/download/majority-report-drugs-for-dollars-how-medicaid-has-helped-fuel-the-opioid-epidemic

And https://www.wsj.com/articles/the-opioid-dens-of-medicaid-1517009331

Prescribers allow too many (opioid) pills before individual patients are properly evaluated and treated.  And as a condition of further treatment. The ED is not the best venue to do such evaluations. Funding for addictions treatment is insufficient in Medicaid and other third party pay, almost always program-based rather than patient-centered, programs funded by Medicaid are not properly evaluated and compared for their effectiveness (cost-effectiveness), and demonstrated continuity of relationship-based, patient-centered pain and addiction care with qualified personnel is not currently the key to funding care by third parties.

Pain clinic physicians have been unfairly targeted as opioid enablers.

Opioids will be a political issue in 2018. We should empower patients with money, information, and sound health care choices. I had a lot of Medicaid people who paid cash to see me and get on track reversing opioid dependency. Carfentanylhttps://en.wikipedia.org/wiki/Carfentanil? Law enforcement? Yes. Yes.

Both supply of and demand for opioids must be addressed.