Minnesota Physician cover stories

November 2017

Past MP cover stories

Reducing failure to diagnose claims

What to do when patients decline cancer screening

 

By Ginny Adams, RN, BSN, MPH, CPHRM

 

Diagnostic error is the most frequent allegation in medical professional liability (MPL) claims involving death, according to the National Patient Safety Foundation in 2014. It is the number one cause of MPL claims for all primary care specialties, radiology, and emergency medicine. Claims alleging a failure to diagnose cancer are among the most numerous and most costly examples of diagnostic error. Several issues underlie many of these cancer claims, including the failure to offer or provide appropriate cancer screening.

 

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A better way to treat chronic pain

Alternatives to opioids

 

By Nima Adimi MD, MS

 

Chronic pain is one of the biggest medical problems facing the world today. As medicine advances and people live longer the incidence and prevalence of chronic pain will only increase given the inevitable degeneration of our bodies. Chronic pain is an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage for at least three months. As a physician I have always been interested in statistics. Numbers put things into perspective for me so here are some alarming statistics regarding chronic pain:

 

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The value of Medicaid

A safety net for children

 

By Kelly Wolfe

 

Imagine you’re pregnant and you unexpectedly go into premature labor, delivering your baby two months early. While you have health care coverage through your employer, you discover upon discharge from the hospital that your insurance won’t cover the 24-hour nursing care your baby will require, nor does it cover the equipment or medications your infant will need to survive. Thankfully, your child is eligible for Medicaid and you can now access these services.

 

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Opioid Prescribing Improvement Project

A safety net for children

 

By Kelly Wolfe

 

Imagine you’re pregnant and you unexpectedly go into premature labor, delivering your baby two months early. While you have health care coverage through your employer, you discover upon discharge from the hospital that your insurance won’t cover the 24-hour nursing care your baby will require, nor does it cover the equipment or medications your infant will need to survive. Thankfully, your child is eligible for Medicaid and you can now access these services.

 

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Quality reporting

The importance of accounting for social conditions

 

By Paul Kleeberg, MD, and Phil Deering, BA

 

Like many Minnesota physicians, Dr. Lynne Ogawa first saw her Minnesota Statewide Quality Reporting and Measurement System (SQRMS) outcomes toward the end of the last decade. At the time, the family practice doctor saw patients at the Fremont Clinic, located in the heart of North Minneapolis.

 

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Why just retire?

Consider physician emeritus

 

By Michael J. Weber, JD, and Nancy Lee Nelson, JD, MPH, RN

 

If you are like many other Minnesota-licensed physicians, you might be unaware of the option to retire as a “physician emeritus.” To retire as a physician emeritus, a physician has to complete a short application with the Minnesota Board of Medical Practice.

 

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Regenerative Medicine Minnesota

Transforming the future of health care

 

By Jakub Tolar, MD, PhD, and Andre Terzic, MD, PhD, FAHA

 

We have grown accustomed to the medical miracles—antibiotics to combat infection; transplantation to replace failed organs; and biologics to control high cholesterol, rheumatoid arthritis, or psoriasis—that have transformed patient care. Despite remarkable advances, many serious health problems resist conventional medicine and surgery, causing suffering and shortening lives.

 

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The Minnesota Adult Abuse Reporting Center

Protecting the vulnerable

 

By Commissioner Emily Piper, JD

 

An older adult woman living in northern Minnesota was at her most vulnerable—recovering from surgery after a stroke—when she became the victim of financial exploitation by her own daughter.

 

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The CARES Model

A way to engage your patients

 

By Archelle Georgiou, MD

 

Sixty-two percent of Americans say they want to deliberate with their physician about their treatment options. And, to help make the right choices, consumers have been armed with an array of health information sites, symptom checkers, cost calculators, and provider quality scores and report cards.

 

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Minnesota Prescription Monitoring Program

Important updates responding to an epidemic

 

By Barbara A. Carter

 

In a recent survey conducted by the American Medical Association, in which 44 of the 49 state prescription drug monitoring programs (PDMP/PMP) responded there was a 180 percent increase, between 2014 and 2016, in the number of physicians’ and other health care professionals that had registered for an account with a PDMP/PMP.

 

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the opioid epidemic:

Complex problems, complex solutions

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and be a part of the discussion.

Thursday, April 26, 2018, 1-4 pm

The Minnesota Health Care Roundtable is a semi-annual conference featuring a panel of stakeholder group experts in a moderated discussion before a live audience covering topics that affect the evolution of health care policy.

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Before May 4th, 2018

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Before January 10th, 2018

Recognizing Minnesota physician volunteers

A better way to treat chronic pain

Alternatives to opioids

 

By Nima Adimi MD, MS

 

Chronic pain is one of the biggest medical problems facing the world today. As medicine advances and people live longer the incidence and prevalence of chronic pain will only increase given the inevitable degeneration of our bodies. Chronic pain is an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage for at least three months. As a physician I have always been interested in statistics. Numbers put things into perspective for me so here are some alarming statistics regarding chronic pain:

 

  • Over 100 million Americans and 1.5 billion people worldwide struggle with chronic pain.
  • Chronic pain is the number one cause of disability in the U.S.
  • Seventy-seven percent of people with chronic pain report feeling depressed due to their pain.
  • Twenty percent of people with chronic pain have taken long-term disability leave from work.
  • Thirty-six million people have taken days off of work in one year due to chronic pain and we can estimate about $300 billion of lost productivity due to this.
  • Only 23 percent of patients with chronic pain have found opiates effective.
  • The most common types of chronic pain are low back pain, headache/migraine, and neck pain.

 

These statistics make it clear that there are a lot of people suffering and it not only affects their physical and mental well-being, but also negatively impacts them financially. Chronic pain is real and is not going anywhere so we need to learn how to deal with it!

 

Opiates as a solution

Unfortunately, chronic pain has become synonymous with the use of opiates and this association needs to be dissolved. Managing chronic pain with opioid medications has become increasingly more dangerous given the opioid epidemic in the U.S. According to the CDC “the overdose death rate has tripled from 1990 to 2013” and is the leading cause of iatrogenic death in patients. Beyond this, physicians are now being held liable for deaths, accidents, and intentional overdoses due to prescribing habits.

 

But, opiates can have positive uses as well. Overall they are non-toxic to our organs as opposed to more commonly-used drugs like NSAIDS and acetaminophen. They also provide good analgesia in the short term. The problems are obvious and include tolerance, hyperalgesia, addiction, and abuse to name a few. Given that Minnesota is where Prince called home, there is a heightened awareness to the opiate problem and a sense of urgency to suppress the epidemic. Given all of this, there is an increased need for physicians, especially in Minnesota, to find effective alternatives to chronic pain. The negatives are that there is still nothing available both interventionally and pharmacologically that mimics the immediate and powerful pain relief of opiates but there are options that in the long run provide the same if not better analgesia without the aforementioned risks.

 

Alternate ways to approach pain

When thinking about treating chronic pain, I focus on a four-pronged approach: 1) functionality, 2) behavioral health, 3) medication optimization, and 4) interventions.

 

Functionality

The first thing to think about is functionality because pain relief without a level of functioning is irrelevant. I expect all of my patients to either participate in physical therapy or an intensive home exercise program to make sure that they stay strong and avoid deconditioning. In the past, physicians and others thought that when in pain, patients should protect themselves by resting. Today we know that this is the wrong approach and the best thing is for patients to exercise and continue to stay active. There are rarely any negative consequences to continuing activities when dealing with chronic pain. In the long run, patients end up desensitizing themselves to the pain.

 

Behavioral health

It’s very important for physicians to consider a patient’s behavioral health. As shown in the earlier statistics, 77 percent of patients who have chronic pain are depressed for a variety of reasons. I always make sure that my patients are seeing a pain psychologist/therapist and learning some relaxation techniques or are provided with enough outlets where these needs are being met. The combination of meditation with cognitive behavioral therapy has been proven to be effective. This is probably the most underrated and undertreated part of chronic pain.

 

Medication optimization

It is very important to be sure that patients are optimized from a medication standpoint. Medications should be introduced with the understanding that most, if not all medications prescribed for pain have side effects. This is an important part of the discussion since there are no silver bullets. That being said, there are some good non-narcotic medications available. The most common, since they are over-the-counter, are NSAIDS and acetaminophen. Both can provide good relief at therapeutic doses but are not without their own risks. NSAIDS are thought to contribute to myocardial disease, GI disturbances including bleeds, and kidney dysfunction. Acetaminophen has led to liver toxicity in overuse and even at therapeutic doses. The neuropathic medications most used are gabapentin and pregabalin. Both are good drugs and in the case of gabapentin affordable as well. The problem with gabapentin and pregabalin is that the side effects are hard to tolerate especially in the geriatric population. Other medications including antidepressants like duloxetine, amitriptyline, and nortriptyline are all moderately effective in treating neuropathic pain but the side effects seem to be the limiting factor. Muscle relaxants such as cyclobenzaprine, tizanidine, or methocarbamol are all options that can help a patient with spasms. There are other types of more experimental off-label drugs used and in the pipeline but none are ready to be used in a widespread manner.

 

Interventions

To my mind, the future of pain management lies in interventions. This includes a wide variety of options such as minimally invasive trigger point injections, to implantable devices like intrathecal pumps and spinal cord stimulators. Interventional pain is a relatively new medical specialty that tries to identify and target physical generators of pain by utilizing imaging (fluoroscopy, ultrasound, CT scan) along with minimally invasive techniques. Most of us are familiar with epidural steroid injections, joint injections, and even rhizotomy. We can also use more advanced techniques such as kyphoplasty, neurolysis, and implantable devices. Kyphoplasty and vertebroplasty have provided pain relief for acute and subacute compression fractures for years. These injections have helped people with pain and disability get back to work sooner than expected and stay off of permanent disability. While spinal cord stimulation has been around for many years, it has had an infusion of advances in the past couple of years. These advances include high frequency stimulation, burst stimulation, and dorsal root ganglion stimulation. Treating people with spine mediated pain has always been pretty successful, but some of these new technologies have allowed physicians to better treat the more difficult pain conditions such as pelvic pain, abdominal pain, and diabetic neuropathy. This is an exciting time in the field of pain medication given all the advancements. As the therapies continue to improve, our ability to treat pain without resorting to narcotics improves.

 

Conclusion

In the past, chronic pain was considered the worst possible diagnosis as it most likely meant long-term disability with no specific diagnosis or treatment. Today, with the evolution of advanced imaging, new minimally invasive interventions, and innovations in implantable pain control technologies, interventional pain physicians are able to accurately diagnose and effectively treat chronic debilitating pain previously considered untreatable without high-dose narcotics. We always recommend our primary care and surgical colleagues to consider referral to a pain management specialist prior to putting patients on high-dose narcotics or sending them for high-risk surgeries.

Nima Adimi, MD, MS, is board-certified in pain medicine and anesthesiology. He joined the MAPS team in 2016 and currently sees patients at the Edina and Chaska locations. Being part of an interdisciplinary team gives him the opportunity to help change the way pain is approached.

 

Nima Adimi, MD, MS, is board-certified in pain medicine and anesthesiology. He joined the MAPS team in 2016 and currently sees patients at the Edina and Chaska locations. Being part of an interdisciplinary team gives him the opportunity to help change the way pain is approached.

 

Minnesota Physician Publishing Inc. © 2017