Primum Non Nocere

Details

• Personal Author:
  Franklin GM
• Description:
  Every year, on the Jewish Day of Atonement, Yom Kippur, a part of the liturgy recited is a brief paragraph of single phrases separated by periods; each phrase is an admission of a prior years potential wrongdoing, and one pounds their chest with a fist with the recantation of each phrase, such as "we have framed falsehood," "...and have caused others to err." A similar set of phrases pertinent to what has transpired over the past 15 years related to the treatment of chronic pain with opioids might be "Death. Overdose hospitalization. Overdose ED visits. Falls and fractures in the elderly. Infertility. Neonatal abstinence syndrome. Dependence. Addiction. Life-long disability. Loss of family and community." I am not going to question the initial motives of pain experts who believed that if opioids could comfort those at the end of life with horrible diseases, perhaps the same could be said for comforting those in chronic pain. The problem is that this precept was based on insufficient scientific evidence that such treatment would be safe and effective. The balance scale now appears to be heavily weighted: little to no evidence of long-term efficacy, particularly for clinically meaningful improvement in function, and terrible and potentially enduring harm. For drugs synthesized to be only a few atoms different than heroin, what did thought leaders in the field of pain think would happen? In Washington State (WA), we have begun to make a dent, but only a dent, in a state that started out in the highest tertile of fatality rates. This likely has occurred because of broad agreement among our academic and pain leaders that if you want to prescribe opioids for chronic pain, do so with all the best practices and universal precautions that, used prudently, might help avert disaster. Our state guidelines include every publicly available, validated brief instrument any prescriber might need to successfully prescribe opioids should they choose that treatment path. This would include documenting pain and function, and opioid dose in morphine equivalents (MED), at every visit. Not doing so is akin to flying blind. The crucial but much maligned dosing threshold only says that if you have escalated doses to 120 mg/day MED and if the patient has not substantially improved in pain and function, take a deep breath and either hold the line or ask for some help. This is a new "set point" for prescribers to keep in mind, not a line in the sand. In one recent randomized trial, dose escalation was not associated with improvement in pain and function, and misuse/noncompliance occurred in 27% of patients. Primary care prescribers with greater availability of tools and resources may be less likely to abandon their patients with chronic pain altogether. State Prescription Drug Monitoring Programs will also help improve care delivery tremendously, but these programs are underused, underfunded, and do not allow interoperability across states and all health care systems. Payers need to step up to the plate and pay for more effective, mostly nonpharmacological treatments for chronic pain. Multidisciplinary pain services, cognitive behavioral therapy, and graded exercise are all proven effective in the treatment of subacute or chronic low back pain but are rarely used and often not covered. We are experimenting, in WA workers' compensation, with a medical home model with incentives for the prevention and more effective treatment and care coordination of chronic pain in injured workers. In WA, we still have a huge hole to dig out of. How big is your State's hole? It is time to stop wailing, and to get down to business. [Description provided by NIOSH]
• Subjects:
  Delivery Of Health Care Drug Therapy Occupational Health Safety
• Keywords:
  Drug Therapy Medical Care Prescription Drugs Treatment Workers Compensation
• ISBN:
  1526-2375
• Document Type:
  Text
• Funding:
  Grant
• Genre:
  Journal Article
• Place as Subject:
  OSHA Region 10 ; Washington
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Volume:
  14
• Issue:
  5
• NIOSHTIC Number:
  nn:20056433
• Citation:
  Pain Med 2013 May; 14(5):617-618
• Federal Fiscal Year:
  2013
• Performing Organization:
  University of Washington
• Peer Reviewed:
  False
• Start Date:
  20050701
• Source Full Name:
  Pain Medicine
• End Date:
  20250630
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:d785814dcdcffcd89f3b1f225867590b1da171d7b9853ad0d70bb256a8b80999af7e4f8d5829a88d4110ba1df1f7353e890f912c3dfa4f7c9d786e74c6fbb320
• Download URL:
  https://stacks.cdc.gov/view/cdc/214039/cdc_214039_DS1.pdf
• File Type:
  [PDF - 156.73 KB ]