Vermont Academy of Family Physicians

The Vermont Medical Society Education and Research Foundation today released Safe and Effective Treatment of Chronic Pain in Vermont, a whitepaper detailing the many challenges health care providers face in providing safe and effective treatment to persons with chronic pain in Vermont and the role those challenges play in prescription drug abuse.
 
Developed through structured interviews with nearly 40 professionals involved in the treatment of chronic pain and addiction, the report aims to influence public policy by recommending concrete improvements to the care system in the state, including: 

• Creating a single set of recommendations for treating pain in Vermont;
• Improving the Vermont Prescription Monitoring System;
• Educating the public to expect best medical practices;
• Evaluating the approach of professional oversight;
• Differentiating the role of law enforcement from the role of care giver; and,
• Discouraging payment policies that encourage pill prescribing.

 
“These are practical things we can do tomorrow that will make a big difference in the way Vermonters are treated for chronic pain and potentially reduce prescription drug abuse,” said Cy Jordan, M.D., the Foundation’s director and lead author of the whitepaper.  “Many of them will require new legislation, modified policies or increased funding, but they are inherently doable.  We hope that the legislature and administration dig deeply into this report and seriously consider each of its recommendations.”
 
“This report provides valuable insights regarding the growing challenges faced every day here in Vermont by doctors and hospitals as they provide care for patients with chronic pain,” said John Brumsted, M.D., president of the Foundation. “This document is intended to not only be a reference tool, but also a document that will inspire action to address these problems.” Dr. Brumsted is also president and chief executive officer, Fletcher Allen Health Care.
 
The Issue
The report captures the frustrations of many in the health care provider community, who in an environment of increased emphasis on prescription drug abuse prevention often find themselves torn between ensuring that their patients do not suffer undue pain and reducing the flow of prescription drugs diverted to illicit uses.  A primary care physician interviewed for the report said that the treatment of non-malignant chronic pain is the “most difficult problem that primary care practitioners have to deal with,” while another called dealing with drug-seeking behavior one of the most unpleasant aspects of medical practice, bemoaning the extent to which doctors must function “as judge and jury” when dealing with pain complaints.
 
The situation is so fraught with danger, says one provider, that physicians often find themselves threatened with physical harm.
 
“Abuse, misuse, diversion, and addiction are the most pressing safety issues in my community,” said a medical pain specialist quoted in the report.  “Physician safety is part of this, in terms of the stress caused by patients in clinics, patient threats and the potential for actual physical injury.  At our regional pain management center they have three distress buttons in the clinic that will call security; a call happens almost every week.”
 
Key Findings
One of the most revealing insights uncovered by the report is how reimbursement for care may be unintentionally fueling over-prescribing of narcotics and the addictive and illicit uses that result from it.   
 
“One very big issue is how the insurance companies are actually driving a lot of the dependence on opioids,” said one primary care physician in the report.  “For example, research shows that for chronic, non-specific low back pain, chiropractic manipulation, acupuncture and massage are all helpful. Yet many insurance companies won’t cover these.  But they will cover the Percocet, which has not been proven to be helpful in research.”
 
An obstetrician concurred, saying “It would be nice if there was a way to pay for treatments other than opioids.  Medicaid pays for opioids, but it is difficult to even get [physical therapy] covered for patients who need it long term … but it is hard, particularly for low-income people, to access these treatments.”
 
“What gets paid for and by who is a huge driver in treatment and prescribing patterns,”  said Dr. Jordan, a former family practitioner and pediatrician who has been involved in health care policy and analysis for nearly two decades.  “This is something that needs to be looked at to see if there is a better way.”
 
Another key finding of the report is the health care community’s strong support of the Vermont Prescription Monitoring System coupled with its desire to see a number of improvements to it.  Among the improvements suggested by providers are providing real-time access to prescription information, linking the system to other health information technologies, and including Veterans Affairs and out-of-state prescriptions.  
 
The whitepaper was developed by the Foundation with support of the Vermont Medical Society,the Vermont Health Department’s Division of Alcohol and Drug Abuse Programs (ADAP) and with funding from The Physicians Foundation and Purdue Pharma.  It is available online here.