The questions about pain seem harmless:
During this hospital stay, did you need medicine for pain?
How often was your pain well-controlled?
How often did the hospital staff do everything they could to help you with your pain?
Part of a survey routinely given to patients on Medicare or Medicaid, the answers to these questions are used to determine how much medical facilities are reimbursed by the federal government.
Doctors across the country point to the survey as just one example of how emphasizing pain treatment puts pressure on them to overprescribe painkillers.
They feel that pressure from the patients who expect a pill for every ailment and from some patients who may be addicts.
They feel it from the pharmaceutical companies that used deceptive advertising about the safety of opioids.
They feel it from their bosses who are under pressure to get high scores on patient satisfaction surveys.
“Doctors have been caught in the middle of this,” said Dr. Nancy H. Nielsen, former president of the American Medical Association.
At a recent medical conference, she spoke of these pressures on physicians.
“People universally were nodding,” said Nielsen, who is also senior associate dean for Health Policy at the University at Buffalo School of Medicine. “That is the perception.”
Centers for Disease Control has declared “an opioids overdose epidemic” in the United States, as record numbers of people are abusing pain killers and turning to the cheaper alternative of heroin.
At the same time, doctors, addiction experts and families of people who died from overdoses are demanding changes in policies about treating pain. They also are calling for changes in attitudes about how pain should be treated.
That is starting to happen.
This summer, the Centers for Medicare & Medicaid Services announced a proposal to stop using the answers related to pain treatment as part of its funding formula for reimbursing hospitals. The agency said it would keep the questions in place while it explored alternatives. More than 2,800 comments were submitted online following the proposal, and a ruling on how to proceed is expected to be announced around Nov. 1.
One doctor's experience
Dr. Jose G. Perez-Brache, a local emergency room physician who has been personally touched by the opioids epidemic, shared an experience he said he had three years ago.
A woman came into the emergency room at Kenmore Mercy Hospital, saying she had fallen in the bathtub and that her back hurt, he said
Perez-Brache gave her a thorough physical exam, he recounted. Sensing there was something other than a back issue involved, he ordered a urine test and a CT scan. The CT scan showed no signs of any injury but the urine test came back positive for opiates, the doctor said.
Perez-Brache told the patient about the test results and she immediately walked out of the ER. The doctor surmised that the woman was “doctor shopping” for someone to write her a prescription for an opiate.
Some time later, the patient filed a complaint against Perez-Brache, saying he wouldn’t treat her pain and he was asked by the hospital to write a letter detailing what happened.
The doctor ran into an administrator at the hospital and asked about the response letter he had written.
The administrator told him, according to Perez-Brache: “I don’t care. Make them happy. I don’t want any more complaints.”
Perez-Brache said he was stunned.
“It really took me back,” he said.
In response to Perez-Brache’s allegation, Catholic Health officials said Catholic Health never would ask a doctor to give any kind of medical care that is not medically necessary.
“In Catholic Health, we take patient complaints seriously and investigate matters of concern,” said Dr. Brian J. D’Arcy, Senior Vice President of Medical Affairs and Chief Medical Officer of Catholic Health.
“We expect doctors working in our hospitals to treat patients with compassion and respect, however, we would never request a physician administer medical care, including pain medications, that is not clinically necessary.”
A personal reason to come forward
Perez-Brache acknowledged that the complaint from the woman claiming back pain wasn’t the first time a patient has complained about him. He said he has received complaints for lecturing patients who are obese about making better lifestyle choices to help control their weight and from smokers he has urged to quit cigarettes.
At the time of the incident with the back injury patient, Perez-Brache was splitting his work between Kenmore Mercy and Mount St. Mary’s Hospital in Lewiston. A few months later, he left Kenmore Mercy to work full time at Mount St. Mary’s Hospital in Lewiston.
Perez-Brache decided to tell The Buffalo News about the experience he had in 2013 to illustrate what doctors and hospitals are facing and also because of a personal tragedy. Two years ago, his girlfriend’s daughter, Marlee DeFazio, died of an opioid overdose in their house in Hamburg. She was 23.
Perez-Brache and his girlfriend knew DeFazio was abusing pain pills. She received outpatient counseling and had moved in with Perez-Brache and his girlfriend.
Then on March 31, his girlfriend came home and asked, “Where’s Marlee?”
She found her daughter dead on the second floor.
The police came and showed Perez-Brache six pills. He recognized them right away. Oxycodone.
“You can see why I’m so passionate about it,” he said. “It’s affected me. It’s affected my family tremendously.”
The fifth vital sign
Nearly everyone touched by the opioids crisis believes that attitudes about pain have played a key role in the explosion of painkiller use and abuse.
It goes back to the 1990s, when there was a call for pain to be treated as “the fifth vital sign,” said Dr.Timothy Gabryel, president of the Medical Society of Erie County and medical director of Mercy Hospital.
“That set an expectation that there should be a pill for every problem and there should be no discomfort at all,” Gabryel said.
Two highly influential papers were published that argued that opioids that had been developed to treat cancer pain could be used safely to treat more kinds of pain and weren’t addictive, according to a 2013 New Yorker article “Who is responsible for the pain-pill epidemic?”
The opioids were greenlighted for treatment of non-cancer pain, and soon drugs like oxycodone and hydrocodone were routinely prescribed, often 30, 60 and even 90 days worth at a time. Between 1999 and 2014, sales of prescription opioids quadrupled, according to the CDC.
Patients came to expect their pain to not only be addressed, but eradicated. It’s no wonder.
Walk into any ER or doctor’s office these days, and one of the first questions you are likely to be asked is about pain. You might be asked to rate your pain on a scale of zero to 10 or point to one of a series of cartoon faces on a chart, ranging from a smiley face to a bright red face with tears streaming down.
With the skyrocketing addiction problem and overdoses, medical providers are taking a step back and re-examining prescription protocols.
“I think now, as the scene has changed and we’ve seen more negative outcomes … everybody is backing away and saying: Wait a minute. You should only prescribe for seven days,’” Gabryel said.
A national coalition of medical and addiction professionals called Physicians for Responsible Opioid Prescribing identified earlier this year two sources of pressure on doctors: the patient survey used by Centers for Medicare and Medicaid Services and the “Pain Management Standards” of the Joint Commission on Accreditation of Healthcare Organizations, one of the major accrediting organizations in the country.
That national coalition, which includes Anne Constantino, president and CEO of Horizon Health Services in Buffalo, and Avi Israel, president of Buffalo-based Save the Michaels of the World, asked the federal agency to remove the questions altogether.
“Hospitals are financially incentivized by [the Centers for Medicare and Medicaid Services] to obtain high scores on HCAHPS Survey questions,” the group wrote in a letter. “The questions on the Survey pertaining to treatment of pain have had the unintended consequence of encouraging aggressive opioid use in hospitalized patients and upon discharge.”
The letter pointed to a study that found that doctors prescribe opioids in more than half of nonsurgical hospital admissions.
“While there is no empirical evidence” that pain questions “unduly influence prescribing practices,” the Medical and Medicaid agency said in a news release in announcing proposed changes to how the survey is used, “we propose to remove the pain management dimension from the Hospital Value-Based purchasing program to eliminate any potential financial pressure clinicians may feel to overprescribe pain medications.”
The same agency acknowledged that it had heard concerns about the pain questions and that some hospitals were using the survey results to incentivize individual doctor, nurses and hospital staff. The survey, the agency said, “was never intended to be used in these ways.”
The agency said that it was exploring new questions to more appropriately address pain and conducting research on the clinicians’ concerns and to “determine if there are any unintended consequences that link the Pain Management dimension questions to opioid prescribing practices.
The proposed changes and recognition about the role that putting too much emphasis on pain can have are important first steps, Nielsen said.
“This can’t happen soon enough,” Nielsen said. “But it doesn’t go far enough.”
She would like to see the pain questions removed completely.
The Joint Commission
The national physicians coalition also wrote to the Joint Commission, saying its policies on pain promote the routine pain assessment of all patients, even when it doesn’t make sense.
“The Pain Management Standards foster dangerous pain control practices,” the physicians group wrote in a letter in April, “the endpoint of which is often the inappropriate provision of opioids with disastrous adverse consequences for individuals, families and communities.”
The Joint Commission has adamantly refuted the notion that its policies have led to over-prescription of opioids and published a five-point statement earlier this year to counter “common myths about the Joint Commission pain standards.”
The Joint Commission argued that it “never endorsed pain as a vital sign,” has amended its requirements for pain assessment of all patients, does not require hospitals to reduce pain to zero, doesn’t mention the use of opioids and noted the rise in opioid prescriptions preceded the release in their standards in 2001.
However, the Joint Commission has been criticized for its relationship to pharmaceutical companies that make opioids, particularly Purdue Pharmaceutical, which produces OxyContin. A 2003 report by the U.S. General Accounting Office that found that Purdue was “one of two drug companies that provided funding for JCAHO’s pain management educational programs.”
It also said that “under an agreement with JCAHO, Purdue was the only drug company allowed to distribute certain educational videos.”
The report to Congress said: “Purdue’s participation in these activities with JCAHO may have facilitated its access to hospitals to promote OxyContin.”
In 2007, criminal charges against OxyContin’s makers led to more than $600 million in fines. A holding company affiliated with Purdue Pharma pleaded guilty to a felony charge that it had fraudulently claimed OxyContin would cause less abuse and addiction than competing short-acting narcotics, according to a New York Times article.
While some dispute any direct cause and effect between between making patients happy with over prescription of opioids, Nielsen said, there’s a strong perception that there’s pressure to prescribe opioids.
“Perception is everything,”she said.
And if the perception is that it is making doctors feel they need to prescribe opioids, even against their better judgment, she said, then measures need to be taken.
But others argue that treating pain is an essential part of good medical care and that the vast majority of people given prescription pain killers are not abusing them and are not becoming addicts.
Changing attitudes about pain
The pendulum has swung back to being more cautious about painkillers, and that has led to situations where doctors are now discharging patients who they believe are misusing pain medication.
The Medical Society has fielded complaints from patients who complain they were dumped by their doctors.
Christine C. Ignaszak Nadolny, executive director of the Medical Society, shared a not uncommon patient complaint: “The doctor won’t give me any more scrips.
The patients, fearful of pain and of withdrawal symptoms, will even threaten doctors with going to the streets to buy heroin, she said.
It’s up to the doctors to make the best recommendations for their patients, said Gabryel, medical director of Mercy Hospital, and that’s not always easy.
“Physicians have to say no and we do say no, and sometimes that makes us less popular with our patients. That, unfortunately, is reflected in surveys.”
Nielsen said the challenge is to change people’s attitudes about pain.
“We have to make sure that patients understand that some discomfort is often part of the healing process,” she said.
For too long, people have embraced “better living through chemistry,” she said. “That is a problem. So we have to adjust patient expectations while trying our best to let patients suffer.”
Doctors also need to figure out how to safely treat chronic pain.
“We need more research on that,” Nielsen said.