A noted Denver area pain physician has a dilemma.
He’s retiring. He has over 100 patients who use opioids on a daily basis and he’s pretty sure no other doctor will take them.
Dr. Richard Stieg is not your normal run of the mill pain physician. The 78-year old Aurora, Colorado doctor is a founding member and former president of the American Academy of Pain Medicine who has served the pain world in many capacities. (Here’s his bio)
He understands as well as anyone that given the intense scrutiny that the federal government has put on the medical profession regarding opioid prescribing practices the chances are these patients will not be picked up by other doctors if they are using opioids daily. It’s a trend being seen all over the country.
So he’s created a project to help patients taper off their use of opioids.
“Reaction from patients has been less enthusiastic that I had hoped,” Dr. Stieg told the National Pain Report. “Many have refused to comply with even starting a tapering program.” Dr. Stieg understands that and believes it is a combination of fear and reluctance on part of patients who have used opioids for a long time.
Stanford Pain Psychologist Beth Darnall understands the slow rate of adoption.
“We have done a poor job in giving non-addicted people with chronic pain outpatient pathways to support them with opioid tapering. The program we are testing aim to gives patients pain psychology support with their opioid taper.”
Dr. Stieg read Beth Darnall’s Less Pain, Fewer Pills and the two are working together on the project and have created a study that may ignite a conversation about how pain patients are being treated, or not treated, when it comes to reducing opioid use.
Even for patients who are on board with the program, there are barriers to tapering.
The insurance companies aren’t cooperating with reducing patients’ opioid doses.
“It’s beyond frustrating when you write a new prescription for an opioid that they want pre-authorization even if you are reducing the prescription,” Dr. Stieg said. “It’s an unnecessary roadblock and one that most single doctor practices like mine aren’t staffed to do.”
A doctor’s office can spend 30 minutes on hold waiting to talk to someone at the insurance company and then according to Dr. Stieg, “have to explain my reasoning to someone who doesn’t have the training or the background to understand.”
The insurance companies, he thinks, have put these roadblocks to save money.
Another problem is the big-chain pharmacies who he said “have put arbitrary guidelines based on no science whatsoever into place which make it difficult to write a prescription.”
Dr. Stieg will soldier on with his project because, as he says, “my patients need it.”
The project is time consuming for his practice.
He has sent a letter to each patient letting them know he is retiring and has met with dozens of them already.
Following the initial meeting, there is follow-up by Dr. Stieg and his staff every two weeks for four months. The tapering program includes urine drug screens and tracking for marijuana use.
A second tier of the program, depending on the insurance coverage the patient has, will include follow up with psycho-therapeutic support.
A third tier of the program, also again depending on the insurance coverage, includes biofeedback therapy.
The plain-speaking Dr. Stieg says his program isn’t new.
“30 years ago all pain centers were trying to get people off drugs and center on therapies that addressed the cause of the pain,” he said. “It’s what we are trying to do.”
For Dr. Darnall, the project will gather important information and give a “real world look at what people are going through and what’s needed to better support them. A medical taper alone does not address symptoms of distress that may arise when reducing opioids. We need to provide better pathways to help patients reduce their distress and their pain so that they can succeed with the taper. Also, people need to know that when opioids are tapered slowly and successfully, most patients report less pain.”
And she believes it will make the case that systematic psychological support services should be part of any tapering effort. (Most insurance health plans don’t cover them, which is another hurdle for many chronic pain patients)
But the project goes forward. And there is a lot to learn.
For Dr. Stieg, what is learned from his mandatory opioid tapering program is one last gift he hopes to give the profession of treating pain.
We’ll keep you apprised.