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Easing Pain Without Addiction: Maine Providers Try New Approach

According to the Institute of Medicine, chronic pain affects about 100 million U.S. adults - more than the total affected by heart disease, cancer, and diabetes combined.  Opioids are a commonly-prescribed treatment, but addiction and abuse of these narcotics is skyrocketing.  A new pilot program in Maine aims to help primary care practices better help their patients manage chronic pain and safely prescribe opioids in what some call the "wild west of chronic disease."  Patty Wight reports.

So, what does it mean to be in the wild west of chronic disease?

"There are no standard guidelines, there are no standard measures.  Everybody's doing something different.  Nobody quite knows what to do.  It's just a big old mess," says Lisa Letourneau, the executive director of Maine Quality Counts.

That's the group that is spearheading the Maine Chronic Pain Collaborative, along with the Maine Primary Care Association and Penobscot Community Health Care.  Letourneau says about a third of primary care patients have chronic pain.  And though they are frequently prescribed opioids, she says there's actually no evidence that the drugs are effective for treating chronic pain.

"Unfortunately, it's sort of become the go-to over the last two decades, without necessarily either recognition or appreciation for the potential for dependence and addiction," she says.

This happened for a few reasons, says Letourneau.  One was the introduction of the pain scale - that part of a doctor visit where a physician asks, "On a scale of zero to 10, how's your pain?"

"And the implication was that everybody should be a 'zero,'" she says.

At the same time, Purdue Pharma started heavily marketing opioid narcotic medications, like Oxycontin.  The company would later pay a $635 million fine for deceptive marketing.

"There was some language/messaging that these medications had low abuse potential, and had low risk of addiction," Letourneau says.

Add to that mix primary care providers working in a system that drives them to simplify complex issues because of high patient volumes and short appointment times, says Dr. Noah Nesin, the Chief Medical Officer at Penobscot Community Health Care, and you've got a recipe for disaster.
"My profession has played an important role in creating this crisis by uninformed and inappropriately influenced prescribing practices during the past 20 years," Dr. Nesin says. "And so I think we have a profound responsibility to find the answer, to be part of the solution to this."

Dr Nesin calls prescription opioid abuse the most important public health challenge facing Maine. But trying to switch course for patients that have been using opiods for chronic pain is challenging.

"There's a lot of emotional content to these visits," Dr. Nesin says. "There's a lot of potential conflict and primary care providers are not used to dealing with conflict with their patients.  It's usually a pretty good partnership."

The new Chronic Pain Collaborative, which includes eight primary care practices in Maine, will work over the next year to identify concrete guidelines and treatments that help patients with chronic pain.  They'll collaborate with each other and also connect to chronic pain experts in Arizona through weekly teleconferences.

Eastern Maine Medical's Center for Family Medicine is one of the participants.  Medical Director Dr. Robin Pritham says it's already clear that physicians need to consider chronic pain more as function than elimination.  

"Pain is much more than a number.  It's an experience," Dr. Pritham says. "And what's important is how is that patient experiencing that pain or discomfort? What's it doing to their life? What are they unable to do that they would like to do?"

It's likely, says Dr. Pritham, that physicians will incorporate lifestyle changes to treatments - things like sleeping and eating habits.  Lisa Letourneau from Maine Quality Counts says patients need to ask their doctors about opioid alternatives as well.

"Are there exercise regimens?" Letourneau says. "Acupuncture, physical therapy, chiropractic, massage, other things that could help me manage my pain without being exposed to a long-term potentially addicting and dangerous medication?"

Letourneau says anyone who is prescribed opioids is at risk for addiction.