The Nation’s Opioid Epidemic — Continued Advocacy Needed to Turn the Tide

patGuest Post from Patrice A. Harris, MD, MA
Chair, AMA Opioid Task Force
Atlanta, GA

It is a basic tenet of physician leadership that we run toward an emergency. We evaluate the situation, make an initial diagnosis, and pursue interventions consistent with our education and training. This is as true for clinical practice as it is for policy interventions in state capitals and Capitol Hill. And it is what forms the backbone of the American Medical Association (AMA) Opioid Task Force, with the AANS and CNS playing a leading role.

Understanding that the nation’s medical societies all were undertaking parallel efforts, the AMA convened the Task Force in 2014 to coordinate and focus physician leadership on this issue. The AMA, organized neurosurgery and more than 20 other national, specialty and state societies all agree that there are six key ways in which physicians can act immediately to help reverse the epidemic:

Support physicians’ use of effective Prescription Drug Monitoring Program (PDMP). Many states have upgraded these databases to allow real-time access to current information, and permit delegated access, and some now have the capability for integration with electronic health records. Adoption of user-friendly features that can be integrated into the office workflow are among the reasons that PDMP utilization increased by 121 percent from 2014 to 2016 to more than 136 million queries.

Enhance education on effective, evidence-based prescribing and treatment. This emphasis, which began prior to recent state legislative and federal efforts to restrict opioid prescribing or mandate specific education or training, has led to:

  • More than 118,000 physicians completing courses on opioid prescribing, pain management, addiction and related areas in 2015-2016;
  • More than 12,000 additional physicians becoming certified to provide office-based medication assisted treatment for opioid use disorder;
  • From 2013-2016, opioid prescriptions decreased nationally by 14.6 percent — every state in the nation experienced a decrease; and
  • The AMA recently launched an opioid microsite that includes key resources specifically for neurosurgeons.

pa2Support access to comprehensive, affordable, compassionate treatment. Patients with a substance use disorder must have comprehensive access to treatment, including mental and behavioral health care. We support a comprehensive, interdisciplinary approach to pain management. This means insurance coverage gains must be protected, and payers and employers need to improve access to non-opioid and non-pharmacologic treatments for pain — including evidence-based surgical interventions.

“I also see a big opportunity to really re-introduce into our pain management treatment algorithm other non-opioid medications, such as anti-inflammatory agents, antidepressants and anti-epileptics,” Jennifer A. Sweet, MD, FAANS, the AANS/CNS representative to the AMA Opioid Task Force, said to the AMA last year. “There are many more drugs available than just opioids, and a multimodal approach may represent another key strategy.”

Put an end to stigma. Patients with chronic pain and patients with a substance use disorder deserve comprehensive care and compassion — not judgment.

Expand access to naloxone in the community and through co-prescribing. Due in large part to medical society advocacy, nearly every state has increased access to naloxone and expanded its use, saving tens of thousands of lives.

Encourage safe storage and disposal of prescription medication. The Task Force urges physicians to take three simple steps when prescribing medication

  1. Talk to your patients and educate them about the safe use of prescription opioids.
  2. Remind your patients that medications should be stored out of reach of children and others, and in a safe place — preferably locked.
  3. Talk to your patients about the most appropriate way to dispose of expired, unwanted and unused medications.

pa3There are signs of progress, but much more work remains — and physician leadership remains essential.

First, we need to increase access to specialists in addiction medicine and pain management. This will require policymakers and the health care community working together to increase the number of trained specialists. As provider network rules are enforced, advocates and policymakers need to consider alternative access plans that allow for timely access to care, especially in rural or isolated communities throughout the country. This is critically important as more patients now are dying from heroin and illicit fentanyl than from overdoses due to prescription opioids.

Second, we need to remove administrative barriers that stand in the way of much-needed care.  For example, health insurers should remove prior authorization requirements for medication assisted treatment (MAT) and address other similar barriers to non-opioid and non-pharmacologic pain care — including many of the options used by neurosurgeons.

Patients with opioid use disorder need access to MAT as well as alternatives for pain management. As the nation seeks to change the paradigm for treating pain and encourages physicians to recommend all appropriate pain management modalities to patients, insurance plans need to cover those treatments.

Physicians, policymakers and stakeholders should be working together to advance these solutions. Our patients are counting on us.

Editor’s Note: During the month of September, we encourage everyone to join the conversation online by using the hashtag #painfacts.

Posted in Congress, Guest Post, Health, Pain | Tagged , , , , , , , , , , , |

Spotlight on Pain: Neurosurgeon’s Pivotal Contributions

debGuest Post from Deborah L. Benzil, MD, FACS, FAANS
Chair, AANS/CNS Communications and Public Relations Committee
Mount Kismo Medical Group
Columbia University Medical Center
Mt Kisco, New York

“The greatest evil is physical pain.” – Saint Augustine

“The aim of the wise is not to secure pleasure, but to avoid pain.” – Aristotle

“Of pain you could wish only one thing: that it should stop. Nothing in the world was so bad as physical pain. In the face of pain there are no heroes.” – George Orwell

pain 2As eloquently stated by philosophers and writers, pain is a universal and ubiquitous enemy. In the long and arduous battle to defeat this tenacious foe, neurosurgery has fought hard and can count many crucial victories. In today’s social media fueled world, the intricacies and complexity of pain have been reduced to a cliché: “the opioid crisis.” While there is no doubt that the rise in opioid abuse and related deaths is a serious concern, limiting engagement just to this topic is unlikely to prove the right tactical maneuver. However, the recent focus of attention provides an excellent opportunity to enhance public awareness to less appreciated aspects of this, “enemy of human happiness” (Arthur Schopenhauer).

The spectrum of important concepts about pain include:

  • Understanding pain generators (mechanical, inflammatory, degenerative, vascular, tumor, etc.);
  • Investigating the neurophysiology and neurochemistry of pain, particularly for translation to prevention and treatment of pain;
  • Optimizing treatment interventions spanning prevention, nonsurgical and surgical-including innovations that enhance quality outcomes (minimally invasive, surgical adjuncts, surgical safety, and more);
  • Studying components that impact outcome to ensure the right treatment for the right patient at the right time;
  • Designing meaningful education programs that span from medical school through graduate to postgraduate levels;
  • Developing safe and effective mechanisms to control acute (especially post-surgical) pain;
  • Enhancing utilization of proven non-narcotic interventions, particularly for chronic pain, such as spinal column stimulators and alternative medication; and
  • Making available appropriate programs for those who need help with opioid abuse and addiction.

The pivotal contributions of neurosurgery to this field are too numerous to elucidate fully (see additional resources section for more information) some notable highlights are:

“My focus is to forget the pain of life. Forget the pain, mock the pain, reduce it. And laugh.”  – Jim Carrey

“Mysteriously and in ways that are totally remote from natural experience, the gray drizzle of horror induced by depression takes on the quality of physical pain.” – William Styron

Jim Carrey and William Styron poignantly identify that there is always at least some psychological contribution to the physical manifestation of pain and this further complicates the study, treatment, and understanding of the subject. To name just a few:

  • Many patients have pain with no definable anatomic source;
  • Patients require remarkably different doses of medication for seemingly similar problems; and
  • Some patients are clearly more prone to opioid dependence, addiction or abuse.

painAs you have just read, there are a lot of things to discuss when it comes to pain. Make sure to stay with Neurosurgery Blog throughout September as experts share insights into the complex and important topic of pain. Neurosurgeons are an integral part of establishing optimal care for pain patients, and we will continue to lead the charge to ensure they get the best treatment possible.

Editor’s Note: During the month of September, we encourage everyone to join the conversation online by using the hashtag #painfacts.

Additional Resources:

Selection of Neurosurgery’s Contributions to Pain:

Posted in Guest Post, Health, Healthcare Costs, Nerves, Pain, Spine Care | Tagged , , , , , , , , , |

Ensuring Adequate Pediatric Trauma Care

hsClemens M. Schirmer, MD, PhD, FAANS, FAHA (right)
Vice-Chair, AANS/CNS Communications and Public Relations Committee
Geisinger Health System
Wilkes Barre, PA

Shelly D. Timmons, MD, PhD, FAANS, FACS (left)
President Elect, AANS
Vice Chair for Administration and Director of Neurotrauma, Department of Neurosurgery at Penn State Milton S. Hershey Medical Center
Hershey, PA

2Pediatric trauma — a severe and potentially life-threatening or disabling injury to a child resulting from an event such as a motor vehicle crash or a fall — is the leading cause of death and disability for children in the U.S. More children die of traumatic injury each year in the U.S. than from all other causes combined, with brain injuries being the most common specific cause of death and disability.

Access to timely care is critical in the prevention of death and disability after injury. Only 57 percent of the 73.7 million children in the U.S. during the period 2011-2015 lived within 30 miles of a pediatric trauma center capable of treating all injuries regardless of severity across the spectrum of care; additionally, there is a significant variability between states in this statistic, ranging from above 75 percent to less than 25 percent. In areas without pediatric trauma centers, injured children may have to rely on adult trauma centers or less specialized hospital emergency departments for initial trauma care. Having well-developed trauma systems is therefore critical to provide access to timely neurosurgical and other surgical care, transfer to next-level centers after stabilization and treatment of immediately life-threatening injuries, and provision of specialized services such as rehabilitation after injury.

peds123It is important to note the difference between an organized trauma system and the identification and maintenance of trauma centers. A trauma system is an integrated system involving multiple components of care, which may be organized on a state, regional, or county level, depending on demography, geography, epidemiology, and governmental or regulatory demands. The mature trauma system includes: pre-hospital management and transport; acute care in hospitals; aftercare in rehabilitation hospitals, physician offices and clinics, and the like; community reintegration programs at home, school, and work; quality improvement mechanisms across this continuum; education and research; and epidemiologically-driven prevention programs based upon regional injury patterns. The maturity of trauma systems and the ways in which they are organized is highly variable across the U.S., and rural areas face particular challenges across the spectrum of care. Caring for injured children is incredibly complex, requires specialized knowledge and equipment, and access to specialty physicians. Because most children die or have permanent disability after trauma from injuries to the brain, involvement of neurosurgeons in not only medical and surgical care, but also in the thoughtful development of systems of care, is crucial.

Children are not just “little adults.” Due to several differences that exist between the developing immature brain and the mature adult brain, the impact of injury is different for infants and children. Mechanisms of injury are also different, owing to age-related activities. Therefore, considerations related to acute care and recovery also vary. Examples of differences between pediatric and adult trauma include:

  • Mechanisms of Injury: Tend to be lower impact in children from falls, recreational activity, etc., without the complicating factor of intoxication;
  • Neurobiology: Differences exist in brain “stiffness” due to myelin maturation water content, neuroreceptor number and distribution;
  • Secondary Injury Cascades: Differences may exist in membrane disruption and neurochemical responses, which lead to worsened brain injury in the days and weeks following impact;
  • Responses to Treatment: Surgery, medications, and other therapeutics have differing effects on children; and
  • Responses to Rehabilitation and Recovery: Children are thought to possess a greater degree of neural plasticity and adaptive capability.

Because of these differences, special attention at all levels of care is essential — particularly in neurotrauma — and systems must address the uniqueness of children and their injuries. Furthermore, since injuries are occurring in a developing brain, and most research is done in mature adults, there is a great deal of research to be done on the impact of various forms of therapeutics in children. These research advancements may also help to establish mechanisms for treatment and restoration of function after common adult brain injuries not only from trauma but other processes such as stroke, Alzheimer’s, Parkinson’s, and others.

There are many challenges to be faced and opportunities for improvement in organization and delivery of pediatric trauma care. These include:

  • ensuring adequate and appropriate pre-hospital care for all infants and children;
  • providing access to specialty physicians and pediatric trauma centers;
  • offering continuing medical education and training for providers at all levels;
  • funding research for pediatric traumatic injuries;
  • implementing epidemiologically targeted prevention programs;
  • evolving appropriate age- and development-related outcomes measures; and
  • identifying patient-specific rehabilitation plans and executing them in home environments over the long-term.

As an example of challenges faced in pre-hospital care, one unique challenge is that many emergency medical service vehicles are not fully equipped for pediatric transport. Space for equipment is restricted on both air and ground ambulances, which results in limited availability of all sizes of pediatric airways, cervical spine immobilization devices, and other vital equipment. Furthermore, many emergency responders have limited experience with managing pediatric airways, requiring more frequent education, simulation training, and practice in non-clinical settings. Since airway compromise is a leading cause of preventable death, this is particularly important.

Neurosurgical care is often lifesaving for children suffering from head trauma and brain injuries, and all neurosurgeons are trained to care for injured children, especially in the surgical removal of blood clots that may compress the brain and the prevention and stabilization of brain swelling. Pediatric neurosurgeons have additional training in many aspects of care as relates to infants and children and may assume care from non-specialized neurosurgeons after initial stabilization. Likewise, some neurosurgeons specialize in neurotrauma and neurocritical care and are trained to care for brain injury at all ages. The key is to provide neurosurgical access to all of our population for those time-dependent interventions that save lives, and subsequent sophisticated neurocritical care and neurorehabilitative care to minimize secondary injury and maximize the potential for recovery. This can occur in a variety of configurations and neurosurgeons are actively engaged in designing and implementing trauma systems. However, there is work to be done to provide universal timely and high-quality access to pediatric trauma care through ongoing systems development and support.

peds 4To this end, the AANS and CNS have been founding partners in efforts to establish and promote the efforts of the Congressional Pediatric Trauma Caucus. Representatives from organized neurosurgery, including P. David Adelson, MD, FAANS, and AANS president-elect, Shelly D. Timmons, MD, PhD, FAANS, have participated in several Congressional briefings convened by caucus co-chairs Reps. Richard Hudson (R-N.C.) and G.K. Butterfield (D-N.C.). These events have highlighted the challenges facing pediatric trauma patients and the need to find bipartisan solutions to ensure adequate trauma care for children. As part of this overall effort, the Government Accountability Office (GAO) was tasked with examining various issues related to pediatric trauma. Leaders from the pediatric neurosurgery community provided input to the GAO, including a white paper on pediatric neurotrauma. The resulting GAO report, titled “Availability, Outcomes, and Federal Support Related to Pediatric Trauma Care,” will serve as the basis for future efforts to improve pediatric trauma systems.

Our nation’s children deserve the best we have to offer so that they can have every chance of surviving and recovering when they get hurt. America’s neurosurgeons stand at the ready to provide care and to help make vital improvements in our delivery systems.

Posted in Access to Care, Hard Knocks, Health, Trauma | Tagged , , , , , |