Saturday, March 16, 2019

Do Not Stay Ahead of Your Pain!

I often hear the mantra – “you must stay ahead of your pain, or else.” The president of the American Academy of Pain Medicine, states a common mistake people make, is waiting too long to take pain medication. By the time you’re in pain, you’re starting from behind the eight ball. "It takes a lot more medicine to control pain after it’s started as opposed to starting it ahead of time," he says.[i]Is this true, if I don’t pre-empt my pain I will be doomed to a never ending cycle of playing catch up? There are a lot of smart people and prestigious organizations espousing this theory of staying ahead of your pain so maybe we should move on and accept it as settled science, right?

Well as it turns out, there is a lot more to treating acute pain than sending patients home with a prescription of an opioid mixed with acetaminophen and telling them to just take what you feel you need so that your pain never gets “severe.” Do patients have any idea what this means? Of course no!

Since non-opioid analgesics should be used as the foundation of acute pain management, sending patients home after surgery, for example, with a combination opioid defeats the purpose. 

Rule # 1: Assuming you have no renal or liver disease, you should take close to the daily maximum of acetaminophen and a non-steroidal anti-inflammatory agent around the clock.

Rule # 2: Opioids should only be used in their pure form; they should be taken only when the patient feels their pain is intolerable and then stopped as soon as possible.

Rule # 3: The 24hr opioid prescription dose should be calculated so that the morphine milligram equivalents (MMEs) are less 50 for all opioid naïve patients.

Let’s unpack how these rules fly in the face of current medical management. Most patients are prescribed a combination opioid for acute pain. This means that you will always max out on the opioid component prior to the non-opioid – not good. Most clinician do not calculate the MMEs they prescribe and have no idea at what level an opioid naïve patient is at increased risk for respiratory depression – not good. Patients are not told to take a pure opioid if their pain becomes intolerable while on scheduled non-opioid multimodal treatment – not good.

When patients are coached to stay ahead of their pain they invariably overtreat with opioids due to fear of what “may” occur. By overtreating, you end up suppressing your ability to make endogenous opioids thus causing an amplification of pain once the prescription ends. Post-surgical pain is expected and when treated in keeping with the above rules most patients will be managed with tolerable pain. This tolerable pain allows you to progress with the healing and rehabilitation process, but more importantly, allows your brain to manufacture endogenous opioids – very important. Central sensitization of pain, opioid induced hyperalgesia, the progression to chronic pain, and persistent use of opioids after 90 days, are all the results of overtreatment.

So, the next time you hear the phrase, “stay ahead of your pain,” remember to “stay ahead of the pack” and utilize a non-opioid multimodal foundation first, followed by a pure opioid only when the pain becomes intolerable. This may fly in the face of current medical management, however, last time I checked, this philosophy was a main driver for our current opioid epidemic.

Myles Gart, MD
Dr. Gart is an anesthesiologist 




[i]https://www.webmd.com/pain-management/features/managing-pain-after-surgery#1

The Fallacy of Patient-Centered Care

I often wonder what it was like before patient-centered care became a mainstream catchphrase. Was there a poor relationship between the patient and physician in the out-patient setting? While is the hospital were patient’s feelings, desires, goals, and therapy options ignored? It amazes me that we were able to care for patients more than ten years ago without using a “patient-centered” approach.

Patient- and family-centered care encourages the active collaboration and shared decision-making between patients, families, and providers to design and manage a customized and comprehensive care plan.[1]Under patient-centered care, care focuses more on the patient’s problem than on his or her diagnosis. Patients have a trusted, personal relationship with their doctors. 1Historically, patients have had a better relationship with their physicians than they do today. Today office visits are short to fit in as many patients as possible and during the visit the provider is too busy typing into an electronic medical record than looking the patient in the eye. Years ago, physicians made house calls, spent more time discussing what interested their patients and in smaller communities, patients even called their physicians at home of they had a question.

Marcus Welby, MD has been replaced with UltraSuperSpecialized, MD. Our knowledge of medicine, genetics, pharmacology, and immunology has exponentially expanded, but it has come at a great cost. Fragmented care is what we have today. Patients are referred from one specialist to another often with little education regarding how all the pieces of the puzzle fits together. Patients are supposed to take ownership of their healthcare under this new model. As a physician, I have watched my father go from nephrologist to cardiologist to urologist and then the hospital with urosepsis. Now there was a hospitalist on the case who tried to piece together what had happened with multiple specialists over the past two years. Needless to say, multiple tests were repeated, new specialists were consulted and new medications were added. 

My dad was finally discharged but not before I had spoken to each specialist to coordinate his care and come up with a treatment plan. He had no “ownership” of his healthcare, he trusted in his physicians to treat his condition and get him home as soon as possible. When a patient is admitted with sepsis or appendicitis or an acute myocardial infarction, how are they expected to play an “active” role in their care? Maybe they should google their condition and review the current treatment options with their care team? 

Patient-centered care is a form of value-based care. Governmental agencies and insurance companies are using these new care models as proxies for quality. Since quality is difficult to measure, a patient’s experience or satisfaction with the care provided serves in its place. Unfortunately, we are focused doing what makes the patient and their family “satisfied” as opposed to treating their condition. 

As healthcare providers we are not in the hotel and restaurant management business, we are here to heal. The fallacy of patient-centered or value-based care is that it forces us to allocate resources on an outcome which has little to do with the true quality of care provided. Is the patient a customer and as a customer, is the patient always right? One has to merely look at the current opioid crises to see the error in that logic.

Myles Gart, MD 

Monday, October 8, 2018

One Hospital’s Rx for the Opioid Epidemic

A Nebraska health system introduces a methodology for the assessment and management of acute pain with a goal of decreasing opioid use in the hospital and after discharge.
Neither problems, nor epidemics, occur in a linear fashion. There is usually an ebb and flow to the way issues come to a tipping point, and the opioid epidemic is no different. We will see that this crisis is in part self-inflicted, but more importantly, there is now an opportunity to make a direct impact on this crisis by changing the paradigm by which we assess and manage cases of pain in our nations’ hospitals.
Consider some common misconceptions that have contributed to our current situation before looking at the template for success in treating acute pain.
Misconception 1: In the 1990s, there was an “epidemic of untreated pain.”
A lot of opioids are prescribed based on the patient’s subjective assessment of pain. While this may help make the patient “happy,” it is not in his or her best interest and leads to frequent adverse opioid-related events.
To change the prevailing practice, there must be a crisis. Early in the 1990s, opioids were reserved for cancer pain or acute pain from trauma or surgery, because of their addictive nature. If one says it often enough, the people start to believe it — and such was the case with physician groups/societies beating the drum about the epidemic of untreated pain in our hospitals.
Moreover, when poorly written case reports appearing in prestigious medical journals that expounded the illusion that opioids were not addictive if used “correctly” to treat pain, the dam broke open. No longer restrained by any historical common sense and fueled by a made-up epidemic of untreated pain, prescribing practices began to change — backed by medical societies, pharmaceutical companies and the Joint Commission (the regulatory agency responsible for the safety in and the quality of our hospitals).
By the way, can anyone produce any data to support the premise that there has ever been an epidemic of untreated pain?
Misconception 2: Pain should be the fifth vital sign.
If there is an epidemic of untreated pain, it follows that there must be a way to make the pain “more visible” in an acute care setting. The American Pain Society announced that pain should be classified as the fifth vital sign. Like blood pressure, heart rate, respiratory rate and temperature, pain apparently is now visible, too.
Classifying pain as a vital sign has been the biggest mistake in modern pain management. Pain is a subjective feeling that is impossible to accurately and consistently quantify across patient populations. Therefore, for providers to assess pain as a vital sign, they must ascribe a numerical value to it, such as zero to 10.
If there is an epidemic of untreated pain, and pain is a vital sign — with my pain being a 10 out of 10 — and we are told opioids aren’t addictive, then bring on the drugs until I’m comfortable. Let’s talk about a prescription for the overtreatment of pain. Even the Joint Commission caught on and, in 2002, addressed the problems of using the fifth vital sign as a concept, by describing the “unintended consequences” of this approach. In 2016, the American Medical Association and the American Academy of Family Physicians both recommended dropping pain as a vital sign.
But after nearly three decades, the damage had been done. For example, according to the American Society of Addictive Medicine, from 1999 to 2008, overdose death rates, sales and admissions for substance-use disorder treatment — related to prescribed pain relievers — increased in parallel. The overdose death rate in 2008 was nearly four times more than the rate in 1999. Subsequently, drug overdose is now the leading cause of accidental death in the United States.
Misconception 3: Improving patient experience, which is one of the three pillars of the Institute for Healthcare Improvement’s Triple Aim, has been interpreted as stating that “patients should be treated until they are happy with their pain relief.”
We have all heard the term “patient-centered care,” but what does it mean? As a direct result of addressing and improving the experience of care as recommended by the IHI, in patient-centered care, an individual’s specific health needs and desired health outcomes are the driving force behind all health care decisions and concomitant quality measurements.
The prestigious New England Journal of Medicine says, “Patients are partners with their health care providers not only from a clinical perspective but from an emotional, mental, spiritual and financial perspective.” The 2010 passage of the Affordable Care Act placed financial incentives and penalties on how hospitals ranked with respect to their patients’ experience of care. Embedded in this “experience” was pain control. Hence, since the IHI’s development of the Triple Aim back in 2008, we have morphed into the treatment of patients in hospitals as though it must be a Disney-like experience and the patient must always be correct, especially when it comes to the treatment of their pain.
To improve one’s hospital experience, we must focus on standardized care that will result in high-quality outcomes. Instead, we have seemingly improved the patient experience by equating it with happiness without pain, which is identical to the case of overtreatment with opioids.
Misconception 4: Opioids, if used correctly, are not addictive.
Here is my question: How does one use opioids correctly? More than 60 percent of the pills in the average opioid prescription go unused, indicating that the treatment of acute pain is mere guesswork. Studies report a wide range of opioid use in the percentage of patients who become dependent. The findings appear to vary based on how opioid use is monitored — a condition that requires the prescription, the specific form of opioid and the prescribed dose. In some cases, the rate of addiction has been reported to be as high as 30 percent. Four of five new heroin users usually start out by misusing prescription painkillers.
Here are some questions every patient needs to ask before obtaining an opioid prescription:
  1. If I am younger than 25, do I have more of a chance of becoming addicted later in my life?
  2. If I have a history of drug or alcohol use and consequent disorders in my family, am I more likely to become addicted?
  3. If I use opioids to treat my pain, can it increase the pain that I have?
  4. If I refill my prescription more than once, does it increase the likelihood of addiction?
  5. If I have a predisposition toward or am being treated for anxiety or depression, am I more likely to become addicted?
The answer to every question is “yes.” The explanations:
  1. The younger you are when you are exposed to opioids, the higher the likelihood of addiction later in life. The prefrontal cortex is not fully formed until age 25. This means that alterations in the “feel-good” neurotransmitters, specifically dopamine (released by opioids), can have an effect that predisposes the person toward future opioid use. Because teenagers have an overactive impulse to seek pleasure and less ability to consider the consequences, they are especially vulnerable to the temptations of drugs and alcohol. Moreover, because the internal reward systems are still being developed, a teen’s ability to bounce back to normalcy after using drugs — even those prescribed for acute pain — might be compromised due to the way in which the drugs affect the brain. Another confounding factor in today’s teenage world is the effects of social isolation due to technology, which increases the feel-good power of dopamine release as a result of opioid exposure. 
  1. You are more likely to become addicted to opioids if there is a history of drug or alcohol use and consequent disorders in your family. This comprises important information that must be relayed to a health care provider who feels the need to prescribe opioids to you. 
  1. With opioid-induced hyperalgesia, the opioids themselves increase the body’s sensitivity to pain by overamplifying the pain signals that go to your brain. Some might confuse this with tolerance, but tolerance to opioids is a slow process and can be overcome with increase in dosage. Opioid-induced hyperalgesia is a condition that can be brought on rapidly, sometimes just after the single use of a powerful, short-acting opioid such as remifentanil. In addition, this condition is only made worse by increasing the dosage. 
  1. Multiple refills for prescription opioids are associated with continued use after one year. This might lead to tolerance and entail an escalation in dosage, which later might lead to long-term use and, consequently, physical or psychological dependence. There is a line between dependence and addiction, but you do not want to be in either category. 
  1. Anxiety and depression are fertile grounds for the euphoric effects that follow the dopamine surge from opioid use. When an individual feels better psychologically, their pain is alleviated as well. The concomitant issue arises — what is the goal of treatment? If the acute pain of an event is gone but an individual still asks for opioids, questions should be asked regarding history of anxiety and depression. 
Misconception 5: Opioids are easy to stop once a person has started taking them. 
This issue speaks directly to the facets of dosage and duration. We have already touched upon the fact that a high dose and long duration can lead to dependence and addiction. However, what has not been brought to light is how opioids alter the pain defenses of our bodies. Our brain releases its own endogenous opioids, called endorphins and enkephalins. These powerful neurotransmitters bind to the same receptors as opioids, albeit with less potency. By taking exogenous opioids, one signals the brain that there is no need to produce its own. Thus, when one stops the medication, the body’s ability to deal with “usual” pain is diminished. This brings up an interesting question that will be discussed in great detail when we discuss the new kinds of assessment and the treatment of acute pain in the hospital setting: To what degree should pain be treated with opioids, so as to avoid its unintended consequences? 
A REQUIRED PARADIGM SHIFT 
There is no silver bullet to deal with the opioid crisis. Let us remember that this is not the first time that human civilization has had to deal with this problem. Opioids have been around for more than 3,000 years and, throughout history, there has always been subsequent dependence and addiction. My hope is to use the knowledge we have in addition to lessons learned to make future prudent decisions.
As a result of some of the aforementioned misconceptions, the last three decades of acute pain management have been opioid-based as well as patient-centric. In other words, a lot of opioids are prescribed based on the patient’s subjective assessment of pain. While this may help make the patient “happy,” it is not in his or her best interest and leads to frequent adverse opioid-related events as well as drug abuse. 
This is just a politically correct way of saying that since we have let the patients decide when they’ve had enough opioids, many high-risk patients consequently have paid the ultimate price. 
It is time to move to a 21st century model of pain assessment and treatment in the acute care hospital setting. Let’s make one thing clear: We are not talking about cancer-related pain or chronic pain, but specifically focusing on acute pain because of injury or surgical procedure. Although the same methodology can be used for these other classes of patients, it is beyond the scope of this article. 
Faith Regional Health Services in Norfolk, Nebraska, has embarked upon a unique strategy to assess and manage pain. The trademarked phrase, Opioids Rarely Help Bodily Pain, is not merely catchy but also a mnemonic related to educational learning that serves as the cornerstone of a new acute pain paradigm. 
As is known, the evaluation of pain is extremely difficult because of its subjective nature. However, this new evaluation not only accounts for the patients’ self-assessment but, for the first time in a hospital policy format, incorporates objective measures of pain into a global assessment matrix. 
When we ask the patient to rate their pain using the numeric pain scale, the answer will be a number. More importantly, however, we follow up by asking whether that “number” equates or qualifies their pain as tolerable or intolerable. Our goal is to render the pain tolerable, that allows the patient to meet the daily goals of physical therapy or specific milestones while heading toward discharge. 
To finish our assessment, the objective component must be completed prior to any change in the analgesic treatment. Following are the five pillars based on the Opioids Rarely Help Bodily Pain treatment plan. In most cases, if three out of five of the objective signs are positive, it may confirm intolerable pain. On the contrary, if there are objective signs that suggest overtreatment, then the need to de-escalate analgesic therapy might be indicated. 
Observation. Is the patient grimacing, screaming, diaphoretic, combative, crying, sleeping, drowsy, etc.? This observation must be made after confirming that the physical/verbal symptoms are not because of delirium, hypoxemia, hypercarbia, acidosis or other metabolic issues that may be confused with the outward appearance of discomfort. If the patient appears drowsy, somnolent or obtunded, then overtreatment is indicated. 
Respiratory rate. Respiratory rate is an excellent objective indicator and a guide with respect to analgesic therapy. A normal range of respiratory rate is between 12 and 20 breaths a minute. These are actual breaths associated with ventilation of adequate tidal volumes including not-attempted, shallow or obstructed respirations. As with all the objective measures, the neurologic, metabolic and cardiogenic factors must be considered to validate the observations. A respiratory rate greater than 20 would be a positive indicator, while a respiratory rate less than 12 might indicate overtreatment. 
The evaluation of pain is extremely difficult because of its subjective nature. This new evaluation incorporates patients’ self-assessment and objective measures of pain into a global assessment matrix.
Heart rate. Heart rate is usually elevated when a patient experiences intolerable pain. However, if a patient is on a beta blocker, the heart rate’s response to pain may be masked. In addition, if a patient is hypovolemic, hyperthyroid, hypercarbic or has a hyperdynamic neuroendocrine disorder, the heart rate might still be misleading. But as a general rule, a heart rate that is 20 percent above the baseline would be considered as a positive indicator, while 20 percent below would be an indicator of overtreatment. 
Blood pressure. Blood pressure is usually elevated when a patient has intolerable pain. Again, we must stress that accurate objective measures are reliable only when a patient’s neurogenic, metabolic and cardiogenic states are optimal. As with heart rate, a 20 percent increase over the baseline would be considered as a positive indicator, while a 20 percent decrease would be considered an indicator of overtreatment. 
Pupil size. Pupil size is an often-missed indicator of pain. When a patient has intolerable pain, the pupils dilate. On the other hand, pinpointed pupils indicate the central nervous system’s response to a particular therapeutic opioid level. Thus, a patient’s dilated pupils in an optimal neurogenic, metabolic and cardiogenic state would be considered a positive indicator, while pinpointed pupils might be considered as an indicator of overtreatment. 
PUTTING IT ALL TOGETHER 
The aforementioned method, which is a new kind of assessment of acute pain, would not be complete without a change in the analgesic management. Gone are the days in which orders are written based solely on the patients’ self-assessed numeric values that are equated with a medication for mild, moderate or severe pain. After three decades of using this methodology, there have been no improvements in the management of pain while the complications of opioid overtreatment have continued to escalate. 
Faith Regional Health Services’ approach takes the results of the pain assessment and uses them as a guide for the purpose of analgesic management. At this point, it is important to say that the experience of pain is modulated by efferent pathways present in the brain. Therefore, it is crucial to offer patients nonpharmacological methods to help manage their pain. That said, we have implemented an analgesic pain ladder based on four tiers: Tier I comprises nonopioids, Tier II low-dose opioids, Tier III higher-dose opioids and Tier IV patient-controlled analgesic options. Within Tiers I to III are oral and intravenous alternatives. In addition to the tiers, there is a list of adjunct medications that might be chosen to complement them. Tier I and its adjuncts are scheduled medications, while Tiers II and III are PRN (when necessary). 
This assessment and management matrix allows the migration between the analgesic tiers; this results in escalation, maintenance and de-escalation of analgesic therapy. It is beyond the scope of this article to go into more detail. However, the Opioids Rarely Help Bodily Pain lecture series gives specific cases and scenarios, along with identifying the ways in which clinicians may modify the medications within the tiers. It must also be stressed that high-risk patients should be managed in a higher-acuity setting with commensurate monitoring. 
Our hope is that this new methodology for the assessment and management of acute pain will serve as a template for the rest of the country. The metrics for success are as follows: fewer opioids used each day, fewer transfers to a higher level of care because of respiratory depression, less Narcan use, higher patient engagement regarding pain management, improved length of the stay and no respiratory arrests due to opioid overuse. 
Dealing with cases of acute pain in the hospital setting is a multidisciplinary job. Newer regional techniques using ultrasound, long-acting local anesthetics and multimodal, nonopioid medications are helping to manage patients while using minimal to no opioids. This will directly affect the community. 
If a clinician can minimize a patient’s pain before discharge, this can help decrease the number of opioid pills being used at home. More than 60 percent of opioids go unused, and many work their way into the hands of the public or family members for illicit use. However, we believe this paradigm shift regarding pain assessment and management will help to not only manage acute pain more effectively but improve patients’ safety by decreasing opioid use both within the hospital and after discharge. 
This is one hospital’s Rx for the opioid epidemic. 
Myles Gart, MD, MMM, is director of acute pain management for Faith Regional Health Services, based in Norfolk, Nebraska. He has been an American Association for Physician Leadership member since 1995. 
REFERENCES 
The Joint Commission. Statement on Pain Management. Apr. 18, 2016.
McCarthy M. ACA and the Triple Aim: Musings of a Health Care Actuary. Benefits Quarterly. 2015;31(1):39-42.
Gart M. Pain Is Not the Fifth Vital SignMedical Economics. May 20, 2017.
Gart M. Why Do We Keep Prescribing Heroin for Our Patients?KevinMD.com. Sep. 27, 2017.
Gart M.  Isn't It Time for a 21st Century Pain Assessment?Medical Economics. Aug 7, 2017.
Perelman School of Medicine at the University of Pennsylvania. 100 Million Prescription Opioids Go Unused Each Year Following Wisdom Teeth Removal, Study EstimatesScience Daily. Sep. 22, 2016.
Gart M. You’re Wrong, Pain Is Not a Vital SignKevinMD.com. May 25, 2017.
Dalton C. When Opioids Make Pain WorseNPR. May 3, 2018.
Tennant F. Using Objective Signs of Severe Pain to Guide Opioid PrescribingPain Treatment Topics. June 2018.
Hurd Y, Salsitz E. and Addiction Institute at Mount Sinai Health System. Opioid Addiction FAQ: Experts' Guide to the Hard FactsNew York Daily News. June 23, 2017.
Gart M. The Roots of Opioid Addiction. Omaha World Herald.Sep. 29, 2017.
Perelman School of Medicine at the University of Pennsylvania. Even Small Quantities of Opioids Prescribed for Minor Injuries Increase Risk of Long-Term UseMedicalXPress. May 17, 2017.
Gholipour B.  Most Teens Who Abuse Opioids First Got Them from a DoctorLive Science. Mar. 20, 2017.
Velayudhan A, Bellingham G, Morley-Forster P. Opioid-Induced HyperalgesiaContinuing Education in Anaesthesia Critical Care & Pain. 2014; 14:3.
American Society of Addiction Medicine. Opioid Addiction 2016 Facts and Figures.  
Anson P. AMA Drops Pain as Vital SignPain News Network.  June 16, 2016.
American Academy of Family Physicians. AAFP Commits to Addressing Opioid Crisis. May 11, 2016.

Opioid-free Surgery Has Arrived

As we follow the national opioid epidemic, with greater than five deaths per hour from opioid overdoses, the focus is shifting to methods for limiting an individual’s exposure to these drugs. For most of us, our first contact with these highly addictive medications is after surgery.
Studies now reveal that 60 percent of pills prescribed for pain after surgery go unused. These opioids often make their way to other family members, are kept for continued use by the surgical patient to maintain a feeling of euphoria or even find their way into the community. Limiting the number of pills and refills prescribed is a good start, but should we consider not using opioids, or discharging surgical patients on them, at all? With the advent of new anesthetic techniques and a long-acting nerve-blocking medication, this option is now a reality. Consider two commonly performed surgeries where we are seeing a spike in opioid dependence in relatively young, healthy patients.
Shoulder surgeries and cesarean sections occur on a daily basis across the country. With over 700,000 shoulder procedures and over 1 million C-sections performed each year, thousands of these young-adult patients will go on to be persistent opioid users. There are several pre-existing conditions that can contribute to continued use, such as whether a patient is a smoker or has been diagnosed with alcohol- or drug-based issues or depression, anxiety or chronic pain conditions before surgery, but that is beside the point. It goes without saying that individuals with a genetic or behavioral predisposition to abuse opioids should be forewarned and treated accordingly, but why not avoid the opioid exposure issue with these patients altogether?
Until recently our post-operative pain management for shoulder surgery has been limited to either a single injection of local anesthetic to numb the nerves sensing the pain or placing a small tube under the skin that provides a continuous supply of anesthetic. Both of these techniques have their limitations and drawbacks. However, the FDA has recently approved the use of a long-acting local anesthetic for shoulder surgery patients. We are now utilizing this medication by providing a single injection, guided by ultrasound. Our results have been excellent. Most patients have high levels of pain relief lasting between 48 and 72 hours. Individuals can then transition to acetaminophen and ibuprofen without the need of an opioid.
As with shoulder surgery patients, we can now also apply this long-acting local anesthetic under ultrasound guidance after a cesarean delivery. Obtaining 48 to 72 hours of pain relief again avoids the need, in most cases, for opioid use at home. New mothers have enough on their plate, and our ability to provide long-lasting pain relief without opioids is essential.
These are just two surgical examples of how newer anesthetic techniques and medications can play a role in providing individuals with extended pain relief after surgery. We are applying this knowledge to every surgical procedure and observing dramatic decreases in opioid utilization.
Yes, the era of opioid-free surgery has arrived.

Friday, August 11, 2017

Is it Time to Reevaluate the C-Suite?

“I do not believe you can do today’s job with yesterday’s methods and be in business tomorrow.” – Nelson Jackson

 As the dynamics of our country’s health care system change, so too must our methods of managing the intricate web of patient encounters. We have all heard the buzzwords “population health,” “bundled payments,” “full risk” and “value-based purchasing.” These phrases signal the movement from a reimbursement model predicated on frequency to one based on patient outcomes. In essence, the new reimbursement paradigm forces us to reconsider yesterday’s methods.

 Traditionally, hospitals used their resources to report quality data, as required by the Centers for Medicare & Medicaid Services (CMS). They maximized reimbursements by capturing all patient comorbidities and by working with physicians to minimize the length of stay. This model improved the profit margin with medical DRGs such as CHF, AMI, stroke, pneumonia and COPD by standardizing care, improving quality and lowering costs. Surgical services were the financial engine for hospitals because of their high per-case contribution margin. Administrative oversight was limited mainly to staffing and support services since there was little need for standard evidenced-based practices. Recently, this dichotomy has expanded on a national scale with DRG improvement projects focused solely on medical disease states.

 Now, however, with payment structures shifting away from a DRG-based fee-for-service, surgical services are quickly becoming a cost center. Hospitals thus require an entirely different C-suite structure, and along with that change comes the need for a new administrative skill set.

 ASA has proposed a concept to address the current fragmentation in surgical care – the Perioperative Surgical Home (PSH). The PSH is a patient-centered, physician-led, multi-disciplinary and team-based system of coordinated care. It guides the patient through the entire surgical experience from decision to discharge. The PSH is above all value-based and thus provides a strategic opportunity to engage both employers and payers.

 With the aim of meeting the dual goals of improving workforce health and decreasing productivity loss, employers sit at the forefront of health care redesign. This is a tremendous responsibility that demands an administrative skill set, oversight and vision currently lacking in the C-suite. Senior management positions have ballooned over the years to keep up with the complexities of medicine. In addition to the traditional positions of CEO, CFO, CNE and CMO, hospitals now have a Chief Experience Officer, a Chief Population Health Officer, a Chief Innovation Officer and a Chief Information Officer.  Is the current composition and influence of senior leadership commensurate with changing health care needs? Is it time to reevaluate the C-suite?

 We should base who gets a seat atop the physician executive administrative pyramid on who is capable of reducing clinical variation and fragmentation in care. Leaders should be visionary, capable of working with multidisciplinary teams and able to improve quality in measurable ways. The cost of C-suite positions is no doubt high. The positions, either directly or indirectly, need to reduce costs and improve quality under risk-based and capitated contracts. On the other hand, if there is a managerial gap in a vital clinical area such as surgical services, then organizations need to create positions that will secure the critical outcomes essential for future financial viability.

 Ultimately, I ask: Is it time to break up the chief medical officer role? Historically, the CMO served as the conduit between physicians and senior management, focusing solely on inpatient medical care. In the new health care paradigm, clinical management oversight must span the entire spectrum of a patient’s episode of care. It cannot be confined solely to encounters in the hospital. This oversight is now impossible to manage with one position. It is my belief that the creation of a Chief of Medical Services (COMS) and Chief of Surgical Services (COSS) is necessary for the success of any health care system.


The Perfect Storm
The confluence of clinical complexity, risk contracting and fragmented care has created a fertile climate for the creation of the Chief of Surgical Services as an integral member of the C-suite. No health care organization can succeed without visionary leadership in the surgical specialties. Below is a tentative list of COSS responsibilities:
1.  Coexist in a shared operative environment with maximal utilization of services by developing a sustainable infrastructure that supports the surgeons, anesthesia and the patients they both serve

2. Decrease clinical variation with the aid of robust databases and clinical analytics.

3.  Consolidate high-acuity procedures so as to reach the critical volume necessary for an efficient supply chain, specialized nursing care and standardized anesthetic management.

4.  Develop surgical programs spanning preoperative assessment through post-acute care that demonstrate high quality and value for the surgical patient, in keeping with the ASA’s PSH.

5.  Matrix with medical subspecialties to maximize patient preparation and perioperative management through post-acute care.

6.  Develop centers of excellence for local, regional or national destination surgeries.

 While the benefits in the establishment of the COSS position are self-evident, there are a number of barriers to establishing this new role:

1.  It is a new idea, and health care organizations are risk averse.

2.  In a climate of decreasing reimbursement, adding another C-suite position is a tough sell.

3.  Most CMOs across the country have a primary care background. There is an understandable lack of local knowledge, resulting in the inability to see the gap in surgical leadership or “share the turf” with an additional senior physician colleague.

4.  Nationally, surgical services oversight and visionary planning resides with a COO, who commonly lacks experience in the intricacies of surgical services and may balk at expanding the C-suite table.

 There are currently too many departments and too many chiefs, which has contributed to the fragmentation in services and patient care that we now confront. Any consideration of a new C-suite position must, of course, pass the test of improving coordination and integration in the delivery of clinical services. Equally important is the ability to decrease clinical variation, resulting in higher quality and lower costs. Answering the call would be a physician executive armed with the tools of local surgical service knowledge, proven leadership skills and advanced management training. The following case study illustrates what is at stake:

 EdisonHealth, Westlake, Ohio.

 ■ EdisonHealth selects destination hospital “Centers of Excellence” based on appropriateness of care.
 ■ Hospitals receive an “aggressive, all-in” payment for spine, valve or transplant surgeries.
 ■ Covered patients receive consultations, care coordination (similar to the ASA’s PSH approach), plus travel, food and lodging.
 ■ Destination surgical services are covered at 100 percent.
 ■ The local surgical option requires deductibles and co-payments.
 ■ An employer with 10,000 employees can expect 10 to 20 employees selecting the destination surgery option and up to $2.5 million in health plan cost savings.

 As we can clearly see, when surgical care becomes coordinated, less fragmented, economized and based on large volume, low clinical variation, aligned financial incentives and strong, visionary administrative oversight, the desired financial results will follow.

 With the addition of the newest member to the health care C-suite, the Chief of Surgical Services, we now have the opportunity to fill this senior leadership gap and ensure the viability of systems looking to prosper amid the continued paradigm shift in American health care.

Myles Gart, MD

Pain is not the fifth vital sign

After years of exaggeration, misinformation and a national epidemic of opioid and heroin abuse, the nation is finally coming to terms with the fact that pain is not the fifth vital sign. This heresy, as I understand it, has existed for close to three decades and, in my opinion, has been directly responsible for the in hospital deaths of thousands of patients as well as lethal drug overdoses of hundreds of thousands of American citizens through illicit opioid use.

 The misguided acceptance of pain as the fifth vital sign has been, and still is, the single biggest mistake in the history of modern medical pain management.

 In the early ‘90s, the American Pain Society opined that there was a national epidemic of untreated pain in our nation’s hospitals and announced that pain should be classified as the fifth vital sign. This assertion is riddled with many problems. Vital signs are clinical measurements, specifically: pulse rate, temperature, respiration rate and blood pressure, that all indicate the state of a patient's essential body functions.

 These clinical measures are very objective in character and include an assortment of relevant numerical values. Pain is a subjective feeling that is impossible to accurately and consistently quantify across patient populations. Therefore, in order for providers to assess pain as a vital sign, they must ascribe a numerical value for it, such as zero to ten based on the Universal Numeric Pain Scale.

 As a result of equating pain as a vital sign, medical practitioners must come up with a reliable and effective treatment if and when a patient subjectively rates their pain high on the scale.

 In 1998, the Federation of American Medical Boards issued a policy reassuring physicians that “in the course of treatment,” large doses of opioids were acceptable. In 2001, the Joint Commission mandated that hospitals across the country assess pain on each patient they treat.

 While not stating how facilities should assess pain, the nation relied on what the prevailing though was: pain should be considered the fifth vital sign and treated on the zero to ten pain scale. With the support of the Joint Commission, The Federation of American Medical Boards urged individual state medical societies to make the under treatment of pain punishable for the first time.

 With misinformation and external pressure by state and national oversight agencies, American hospitals and medical professionals were steered toward the over treatment of acute and chronic pain. Failure to comply was tantamount to patient abuse and battery, punishable by citations from medical boards and the Joint Commission.

  Thus, this “virtual” national epidemic of untreated pain and subsequent adoption of pain as the fifth vital sign has, in my view and the view of many clinicians, resulted in the brutal and harsh reality of a national opioid and heroin crisis. As evidence, since pain received this additional focus, the number of prescriptions for opioids has escalated from around 76 million in 1991 to nearly 220 million in 2011.

 Looking at some recent data from the American Society of Addiction Medicine, one can truly see that the adoption of pain as the fifth vital sign resulted in many adverse and unintended consequences:

 ·      Drug overdose is the leading cause of accidental death in the United States. There were 47,055 lethal drug overdoses in 2014 alone. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers and 10,574 overdose deaths related to heroin;

 ·      From 1999 to 2008, overdose death rates, sales and substance-use disorder treatment admissions related to prescription pain relievers increased in parallel. The overdose death rate in 2008 was nearly four times the 1999 rate;

 ·      In 2012, 259 million prescriptions were written for opioids, which, in numeric terms, equates to one bottle of pills for every adult American;

 ·      Four out of five new heroin users started out misusing prescription painkillers. As a consequence, the rate of heroin overdose deaths nearly quadrupled from 2000 to 2013. In 2014, more than 467,000 adolescents were non-medical users of a pain reliever.

 How do we pull ourselves out of this opioid abyss and begin to reverse these sobering statistics?

 First and foremost, we must bury the claim of pain being the fifth vital sign and replace it with a 21st Century pain assessment tool that incorporates objective evidence and measures of pain. We must provide improved pain management education for our healthcare providers. In June 2016, The American Medical Association (AMA) removed pain as a vital sign.

 The AMA was followed, in September 2016, by the American Academy of Family Physicians (AAFP). The AAFP voted to drop pain scores as the fifth vital sign, partly in reaction to being seen as a scapegoat for the nation’s opioid overdose epidemic. Even Tom Frieden, MD, MPH, director of the Centers for Disease Control, has called the opioid epidemic “doctor driven.” But physicians in many specialties have explained that they feel pressure to overprescribe opioids, and do so to attain higher patient-satisfaction scores for themselves and their hospitals.

 The Joint Commission must also take steps to remove the threat of hospital sanctions for the perceived under treatment of pain. The federal government, likewise, through the Centers for Medicare & Medicaid Services, must move toward the removal of the so-called subjective patient assessment of pain from the value-based payments that hospitals receive.

 At the same time, when the shackles of state and federal oversight pressures are finally removed, we must embark on a national education program, with the primary emphasis on safely and effectively managing patients with acute and chronic pain.

 For more than three decades, opioids have been the foundation of acute pain management. In 2014, a database consisting of close to three million patients revealed that 73% of those in hospitals receiving intravenous analgesics received only opioids. That number should be zero! The standard of care for acute pain management should be based on a non-opioid platform, better known as a multimodal analgesic (MMA) approach for balanced pain management. Many professional and regulatory organizations support the MMA approach, since there has been mounting evidence that this method reduces the amount of opioids required, resulting in improved patient safety and outcomes.


Failure to comply with this particular approach would result in unnecessarily exposing hospitals and healthcare providers to medical liability. Reducing or eliminating the need for opioids in the hospital setting is not only a mandatory risk mitigation tool but also a way of improving the prescribing practices outside the walls of healthcare institutions.

 Let us work together to take pain as a vital sign out of our lexicon and begin a new campaign to manage pain in a way that is safe and effective. Inaction is not an option. When faced with the embarrassing fact that the United States makes up just 4.6 percent of the world’s population yet consumes more than 80 percent of the global opioid supply, decide for yourself whether a change in our pain treatment paradigm is urgently needed.

Myles Gart, MD

Isn't it time for a 21st Century Pain assessment?

The evaluation of pain is extremely difficult due to its subjective nature. We need to move to an evaluation of acute pain that not only takes the patient’s perception into account, but also, for the first time, incorporates objective measures of pain into a global assessment matrix.
When a patient is in pain, either from an injury or surgical procedure, the pertinent question should be, “is the pain tolerable?” Each of us has a threshold at which point the addition of an analgesic should be considered to prevent the consequences of untreated acute pain.
  
This threshold should not be based on an arbitrary numerical value, but whether the pain is tolerable for that individual. Once the patient states that their pain is intolerable, we then attempt to correlate this subjective feeling with the following objective measures prior to the initiation, maintenance and escalation or de-escalation of analgesic treatment.

Here is a mnemonic to aid in remembering the objective measures of acute pain:

Opioids Rarely Help Bodily Pain

·      Observation—Is the patient grimacing, screaming, diaphoretic, combative, crying, sleeping, drowsy, etc.? This observation must be made after confirming that the physical/verbal symptoms are not due to delirium, hypoxemia, hypercarbia, acidosis or other metabolic issues that may be confused with the outward appearance of discomfort. Once it is established that the physical signs are due to pain, you can proceed with analgesic treatment. If, however, you have not established that your observation is from pain, or if the patient appears drowsy, somnolent or obtunded, do not give analgesics.


·      Respiratory Rate—In my opinion, respiratory rate in the presence of a patient stating that their pain is intolerable is the most important indicator and guide for analgesic therapy. A normal respiratory range is between 12-20 breaths per minute. These are actual breaths associated with ventilation of a normal tidal volume. They are not attempted, shallow or obstructed respirations. Once it is confirmed that there are no abnormal neurologic, metabolic or psychological issues involved, the respiratory rate may now be assessed. A true respiratory rate greater than 20 with a patient stating intolerable pain is a good indication for analgesic treatment. If, however, the respiratory rate is less than 12, I would not initiate or escalate opioid analgesic therapy.

 ·      Heart Rate—Heart rate is usually elevated when a patient has intolerable pain, but just like any other objective measure, other factors may also come into play. If a patient is on a beta blocker, the heart rate response to pain may be masked. In addition, if a patient is hypovolemic, hyperthyroid, hypercarbic or has a hyper-dynamic neuroendocrine disorder, the heart rate may be misleading.

 ·      Blood Pressure—Blood pressure is usually elevated when a patient has intolerable pain. However, as with heart rate, other factors must be taken into consideration prior to attributing the elevated blood pressure to pain. In addition, all objective measurements should be compared to the patient’s pre-pain baseline. For example, if a patient had a baseline blood pressure of 160/90, then 160/90 would not be considered as an indication of acute pain with this individual.


·      Pupil Size—It is an often-missed indicator of pain, however, pupil size may not only indicate severe pain, but also help guide narcotic de-escalation. For example, if a patient is in pain, there are increased circulating catecholamines from sympathetic stimulation. This leads to pupillary dilation. On the other hand, pinpoint pupils can indicate the central nervous system’s response to a therapeutic narcotic level. Can narcotics be titrated to pupil size? No, but pupil size can definitely be used as a guide in the treatment of acute pain.


Putting it all together

Our first approach in the assessment of acute pain is to observe with critical attention the objective indicators of pain: heart rate, blood pressure, respiratory rate and pupil size. If your evaluation shows a patient who is resting quietly in bed with a heart rate of 60, blood pressure of 120/80, respiratory rate of 12, what then is your initial impression prior to asking for the patient’s “feeling?”


Based on the objective measures, I would maintain current analgesic levels. When asked, however, the patient does not respond how you would expect and rates their pain as intolerable. This is the dilemma facing healthcare providers on a daily basis and their resolution is to escalate analgesic therapy with opioids over 90% of the time.

 This mistake stems from recommendations, such as those from the Agency for Healthcare Research and Quality, whose position is that “patients’ self-reports are the most reliable indicator of their experiences of pain.”

 This line of reasoning is devoid of any objective measures and places the patients’ “self-reports” as the cornerstone in an acute pain management protocol. In addition, the reliance solely on the subjective measure of a patients’ self-report exposes providers to unnecessary legal consequences of under-treatment as well as opioid over-treatment resulting in possible respiratory morbidity, mortality or long-term addiction if this model is continued into the outpatient setting.

 While the legal implications of the way practitioners assess and treat acute pain in the hospital and post discharge are beyond the scope of this article, it is important to note that hospitals, pharmaceutical companies and practitioners are being sued for mortalities related to the inappropriate prescriptive use of opioids.

 As for big pharma, their culpability lies in the inaccurate education and detailing of opioids as either not as addictive or not as dangerous as they truly are.

 The objective measures of pain and critical thinking of where a patient is relative to where they were or where they should be, is requisite prior to the patient’s self-report of whether they view their pain as tolerable or intolerable. When married together into a global pain matrix, these measures will guide the practitioner with the initiation, maintenance, escalation or de-escalation of analgesic therapy. In my experience, nurses feel that they will be reprimanded if they withhold analgesics from a patient who has rated their pain a nine out of 10 on the universal pain scale. This fear routinely leads to unintended consequences.

Myles Gart, MD