Pain management and reduction of opiate use: A proven model meets resistance

Recently, Drug Topics received an e-mail that got us thinking. Commenting on the dilemma of chronic pain patients who face continued restriction of access to opiates, Allen Nichol, a pharmacist entrepreneur in Columbus, Ohio, wrote to tell us about his two-pronged approach to optimizing pain management and reducing opiate use - and his struggles to interest the medical, industrial, and government establishments in it. Here is what he said:

About five or six years ago, I was approached by the Ohio Bureau of Workers’ Compensation. At that time, more than 50% of Workers’ Comp recipients in Ohio were using opiates to treat chronic pain. I was asked to find a way to help reduce opiate use in this population.

After evaluating the literature for more than two years, I came up with a seven-part approach to identify the etiology of patient pain. I presented this to the Bureau’s pharmacy director, who forwarded the proposal to the decision-making body. The proposal was rejected out of hand.

I then tried interesting multiple state cabinet members in the program and also applied for a federal grant for funding from the National Institute on Drug Abuse through the National Institutes of Health. This too was rejected.

Proof of concept

My proof of concept involved more than 200 patient interventions with 56 patients, performed in collaborative practice with a four-member physician group. It yielded the following outcomes:

- Average percentage decrease in pain

Patients currently in treatment: 14.5%

Patients successfully treated and considered at goal: 29.1%

All patients enrolled (including those who withdrew or were overt drug seekers): 18.2%

- Average decrease in daily oral morphine equivalent intake:

Overall cohort: 23.2 mg

In treatment: 34 mg

- Average percentage decrease in daily morphine equivalent intake:

Overall: 15.3%

In treatment: 16.4%

Seven-part approach

I was able to achieve the numbers listed above by using a seven-part approach to pain. Our process is as follows.

Our team meets with patients to discuss certain aspects of their pain.

We evaluate the following lab tests for each patient:

1. TSH (Thyroid-Stimulating Hormone)

2. CRP (C-Reactive Protein)

3. Lipid profile

4. Liver Function Test (enzymes)

5. Basic Metabolic Panel

We treat after we evaluate the following conditions that may be associated with the pain levels:

1. Oxidative stress

2. Inflammation

3. Inflammation due to elevated lipids

4. Muscle spasms

5. Depression

6. Neuropathy

7. Breakthrough pain

Each element has a clinical algorithm attached to it. We suggest treatment in the areas that we believe are implicated in the patient's pain syndrome.

Patients are also weaned from their opiates in a careful fashion. As the other medications begin working and pain starts to subside, the weaning of the opiates then occurs.

Government response

There is a solution to the epidemic of opiate use in the United States. However, in my opinion, the reality is that the states and the federal government only want to give lip service to the problem, rather than to pay to explore innovative approaches to resolving it.

The federal government's answer is tighten up the controls on scheduled medications. The states’ approach is to continue to whine about the problem.

Moving Hydrocodone to Schedule II and scheduling Tramadol was a way to avoid confronting the issues. Approaches like this will continue to fail because decision-makers are not looking for new ideas and are not open to the possibility that a submission from a pharmacist could possibly yield a positive result. 

Provider response

Resistance from some providers appears to be based in aversion to more than just pharmacists. When I presented to the chief medical officer of one healthcare plan, the response was, “Why would I want to know something else that was wrong with my patients that I would have to treat them for?”

In my experience, the only things MDs are probably looking for in general pain management are neuropathy and inflammation, and possibly muscle spasm. They are certainly not applying seven different measures. But the etiology of the problem and pathophysiology of the disease have to be thoroughly explored to help resolve the health deficit of patient.

Judging from the frustration expressed in his e-mail, we suspected that Nichol had experienced more than a few rejections in his attempt to find a backer to help develop his program. We asked him how many companies, agencies, and organizations he had contacted. Here’s the list of the ones that actually looked at his proposal before dismissing it:

·  Aetna

·  American Health Network

·  Anthem Wellpoint; Indiana

·  Blanchard Valley Health System; Findlay, Ohio

·  Blue Cross Blue Shield; South Carolina

·  Buehler’s Grocery; Ashland, Ohio

·  Canyon Medical Center; Columbus, Ohio

·  Cardinal Health

·  CareSource (HMO)

·  Cedarville University; Cedarville, Ohio

·  Centers for Medicare & Medicaid Innovation

·  Centers for Medicare & Medicaid Services

·  Central Ohio Primary Care

·  Churchill’s Grocery; Maumee, Ohio

·  Cleveland Clinic Pharmacy Department

·  Cleveland Clinic Affiliated Physicians

·  Cleveland Clinic Innovations

·  CliniSync

·  CMS

·  Columbus Public Health’s Alcohol and Drug Abuse program

·  COMS Interactive

·  Contractors & Trade Unions; Lucas County, Ohio

·  DECA Health

·  Doctors Hospital (OhioHealth)

·  Fairfield Medical Center; Lancaster, Ohio

·  Fayette County Memorial Hospital

·  Findley Davies

·  Fremont Community Health Services

·  Fremont Memorial Hospital and Fremont Physicians Group; Fremont, Ohio

·  FrontPath Health Coalition

·  Genesis Healthcare System; Zanesville, Ohio

·  Global Cardiovascular Innovation Center; Cleveland, Ohio

·  Healing Our Village (Pennsylvania)

·  Kroger

·  Lakewood Hospital; Lakewood, Ohio

·  Licking Memorial Health Systems

·  Medical Mutual of Ohio

·  Mercy Health Partners; Toledo, Ohio

·  Meijer

·  Memorial Hospital of Union County, Ohio

·  Molina Healthcare (HMO)

·  Mount Carmel-Trinity Health System

·  National Electrical Contractors Assoc. (Ohio/Michigan Region)

·  National Institute on Drug Abuse

·  National Institutes of Health

·  Navitus Health Solutions (Wisconsin PBM)

·  NextGen (electronic medical records)

·  Ohio Bureau of Workers’ Compensation

·  Ohio Department of Alcohol and Drug Addiction Services

·  Ohio Department of Health

·  Ohio Department of Job and Family Services

·  OhioHealth (health system)

·  Ohio Medicaid Managed Care

·  Ohio State Medical Association

·  Ohio State University Health System

·  Pfizer

·  ProMedica/Paramount; Maumee, Ohio

·  PTRX (Texas PBM)

·  Quality Care Products; Toledo, Ohio

·  QZicki Health

·  Samaritan Health Plans

·  Southern Ohio Medical Center, Holzer Clinic

·  Teamsters Local 20, Toledo, Ohio

·  United HealthCare

·  University of California, San Francisco

·  University of Toledo Investment Enterprise

·  Walgreens

What gives?

To date, every entity on this list - including the agency that first commissioned Nichol to come up with a non-narcotic solution for chronic pain treatment - has refused to give this program genuine consideration.

This gives rise to certain questions. Among them:

Isn’t reduction of opiate use in pain management a desirable goal? If it is, why, in the face of documented outcomes, have so many organizations refused to learn more about this protocol or to initiate a pilot project? Do they simply not want to allocate the resources? If not, why not? Are chronic pain patients being dismissed as mere collateral damage, inconsequential casualties in the War on Drugs?

Let us know what you think. Post your comments here or send us an e-mail at drugtopics@advanstar.com.

Allen Nichol, Pharm D, is COO/VP Clinical Operations, CeutiCare Inc., and the 2014 recipient of APhA’s Daniel B. Smith Award. Contact him at 614-506-8128 or allennichol@aol.com.