ASIPP Letter Regarding Oregon's Prohibition of Spinal Injections

[drusso]

November 23, 2016


Dear Friends:


As you are well aware, on July 1, 2016, the Oregon Health Authority (OHA) eliminated coverage for epidural injections. Add to this major draconian decision, without evidence, based on intellectual bias and confluence of interest, on November 8, 2016, the Health Evidence Review Commission (HERC) issued draft coverage guidance strongly recommending against coverage for epidural, facet joint, medial branch, and sacroiliac joint injections for low back pain regardless of etiology.


This problem is spreading beyond Oregon to the entire United States. We have drafted the following letter to be sent from all over the country.


All practitioners can sign onto the combined letter we are sending from ASIPP and all the state societies, but we encourage all your staff, patients, and anyone involved in the care of low back pain to send letters directly to the Oregon Health Authority before December 9, 2016. We are also enclosing a sample letter for your patients to send. The letters can be sent by e-mail to: [email protected]


For your comment to be accepted, it must:

• Be submitted to [email protected] by the listed deadline.
• Contain no .zip files.
• Include name, profession, professional affiliations, address, phone number and email address.
• Not exceed 1,000 words for coverage guidances and 500 words for scope statements.

At the same time it is important to engage state and federal legislators on this issue. ASIPP will be doing everything possible with federal legislators; however, it is important to have state legislators involved especially those who serve on committees concerning health and welfare and any other relevant committees.


Please provide us guidance to whom these letters should be sent. If at all possible we will attempt to send them through CapWiz through ASIPP. We will provide you with that information soon. Meanwhile, we can start sending letters as soon as possible; however, please remember only one letter per person.


Please send us the information related to state legislative committees and the legislators so that we can send the appropriate information to them.


Thank you,



Laxmaiah Manchikanti, MD

Chairman of the Board and Chief Executive Officer, ASIPP

Medical Director, Pain Management Center of Paducah

Clinical Professor

Anesthesiology and Perioperative Medicine

University of Louisville, Kentucky


67 Lakeview Drive

Paducah, KY 42001


Phone: 270-554-8373 ext. 101

Fax: 270-554-8987

E-mail: [email protected]


LM/den


To view some of Dr. Manchikanti's publications go to:

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=manchikanti


"Never forget who was there for you when no one else was." Unknown


"There is no limit to what a man can do or where he can go if he doesn't mind who gets the credit." Ronald Reagan

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[Disciple]

These cuts are likely to get a whole lot worse with cuts in Medicaid funding.

They may not even need "pain management" doctors anymore, except a limited number to do consultations. Everyone gets morphine sulfate ER with prior authorization required for PT, acupuncture.

 

[SeniorWrangler]

You haven't read the guidelines! Nobody gets opioids OR injections.

 

[onewithpain]

In my experience OHA never covered any injections until about a year ago when they had limited coverage for LESIs (not CESIs) for a short time. Now they cover nothing again. They paid Chou to come down and talk to us about the new CDC guidelines. In essence he said that anything that has been covered by insurance in the past is not effective. This was part of the local OHA announcement that they were going to further limit opioid coverage, which was later side tracked by the state OHA announcement that they wanted to limit opioids to 90 mg/day. Chou sounded disappointingly ignorant. He described cauda equina syndrome as "when the loose nerve roots below L1 get squeezed where they come out at L3 or L4", truly his words. He then presented a case of a 50 yo male working as a structural engineer who complains of low back pain aggravated by golfing. Chou prescribes oxycodone. No dx outside of low back pain. At FU appt patient has no relief so Chou ups the dose. This goes on for a while along with an inconsistent UDS and Chou keeps upping the dose. I'm chipping my teeth in the back row. Finally Chou refers him to PT and the patient declines so Chou says he will have to start a taper.

So now OHA says that they will cover PT, acupuncture, chiropractic. There is no evidence to support any injections. They told us that when we start tapering the patients from their opioids we should put a hand over our heart and look them in the eye and tell them "I know you can do this". I told them that we used to all form a circle around the patient and hold hands and sing Kumbaya but they wouldn't cover it so we stopped.

 

[bedrock]

In my experience OHA never covered any injections until about a year ago when they had limited coverage for LESIs (not CESIs) for a short time. Now they cover nothing again. They paid Chou to come down and talk to us about the new CDC guidelines. In essence he said that anything that has been covered by insurance in the past is not effective. This was part of the local OHA announcement that they were going to further limit opioid coverage, which was later side tracked by the state OHA announcement that they wanted to limit opioids to 90 mg/day. Chou sounded disappointingly ignorant. He described cauda equina syndrome as "when the loose nerve roots below L1 get squeezed where they come out at L3 or L4", truly his words. He then presented a case of a 50 yo male working as a structural engineer who complains of low back pain aggravated by golfing. Chou prescribes oxycodone. No dx outside of low back pain. At FU appt patient has no relief so Chou ups the dose. This goes on for a while along with an inconsistent UDS and Chou keeps upping the dose. I'm chipping my teeth in the back row. Finally Chou refers him to PT and the patient declines so Chou says he will have to start a taper.

So now OHA says that they will cover PT, acupuncture, chiropractic. There is no evidence to support any injections. They told us that when we start tapering the patients from their opioids we should put a hand over our heart and look them in the eye and tell them "I know you can do this". I told them that we used to all form a circle around the patient and hold hands and sing Kumbaya but they wouldn't cover it so we stopped.

Likely pointless to cover opioids or interventions for 90% of those on medicaid. What they really need to cover is visits with pain psychology for these patients.

Again, yet another reason not to accept medicaid. I never will again see medicaid in any state as a pain physician.

 

[drusso]

In my experience OHA never covered any injections until about a year ago when they had limited coverage for LESIs (not CESIs) for a short time. Now they cover nothing again. They paid Chou to come down and talk to us about the new CDC guidelines. In essence he said that anything that has been covered by insurance in the past is not effective. This was part of the local OHA announcement that they were going to further limit opioid coverage, which was later side tracked by the state OHA announcement that they wanted to limit opioids to 90 mg/day. Chou sounded disappointingly ignorant. He described cauda equina syndrome as "when the loose nerve roots below L1 get squeezed where they come out at L3 or L4", truly his words. He then presented a case of a 50 yo male working as a structural engineer who complains of low back pain aggravated by golfing. Chou prescribes oxycodone. No dx outside of low back pain. At FU appt patient has no relief so Chou ups the dose. This goes on for a while along with an inconsistent UDS and Chou keeps upping the dose. I'm chipping my teeth in the back row. Finally Chou refers him to PT and the patient declines so Chou says he will have to start a taper.

So now OHA says that they will cover PT, acupuncture, chiropractic. There is no evidence to support any injections. They told us that when we start tapering the patients from their opioids we should put a hand over our heart and look them in the eye and tell them "I know you can do this". I told them that we used to all form a circle around the patient and hold hands and sing Kumbaya but they wouldn't cover it so we stopped.

There are broader politics at play: Fundamentally, there are those who see persistent pain as simply a character flaw and its treatment as a matter of convenience.

I've never held the view that Roger Chou is very clinically astute when it comes to treating pain, but he is nonetheless paid well to conduct GIGO science about pain treatment. His own conflicts of interest are obvious (he's essentially a state employee working for a quasi-state institution) and receives compensation from the Federal government via grant money. He collects PERS and other state benefits at tax payers expense while his employer is actively seeking to purchase a health insurance company (Moda) in which he will likely play a significant role as a population-health analyst.

OHA is an ideologically driven state agency that needs to be held accountable. Its administration's self-dealing with CCO's is nothing short of the greatest boondoggle in Oregon's history. There is a small group of majority party legislators in Salem who understand the need to reform or eliminate CCO's, bring OHA into compliance, and repopulate the HERC with evidence-based, unbiased experts. Everyone who cares about preserving access to pain treatment in Oregon should reach out to them.

https://www.thelundreport.org/content/greenlick-opens-controversial-debate-future-cco-system

 

[onewithpain]

I don't mind that OHA doesn't cover injections as they are a pain to PA and the patients are almost all in need of an extended multi-modal program. I don't like that OHA makes a public announcement out of something that is not a big change in their coverage. It is as if they made the public announcement in order to send a message to the other insurance companies. I would love to speak at their next meeting about the effectiveness of injection therapy but being the local boy with a financial stake in injections I seem to have no credibility.
I could respect Chou's current stand if it wasn't such a change from just a few years ago when he was telling us how he could responsibly and effectively manage high dose opioids. What he did then would currently lead to a disciplinary action from the OMB.

 

[101N]

Roger is a good guy who was influenced - unbeknownst to himself - by the 'concensus' nature of the 2009 guidelines. He learned a lesson and my sense is that from that he cleaves real close to the data
and he's sensitive to COI.

Remember who else was on those guidelines: Fanciullo GJ, Fine PG, Adler JA, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O'Connor PG, Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C;

 

[drusso]

Roger is a good guy who was influenced - unbeknownst to himself - by the 'concensus' nature of the 2009 guidelines. He learned a lesson and my sense is that from that he cleaves real close to the data
and he's sensitive to COI.

Remember who else was on those guidelines: Fanciullo GJ, Fine PG, Adler JA, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O'Connor PG, Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C;

Chou $hit the bed with multiple COI's, but in some circles its considered merely a "confluence" of interest and not a conflict.

http://www.insidesources.com/dysfun...flict-of-interest-in-the-debate-over-opioids/

"Dr. Roger Chou of Oregon Health and Sciences University served both as one of the contributing authors and as a member of the Core Expert Group. In 2009, he was the lead author for opioid guidelines commissioned by the American Pain Society and the American Academy of Pain Medicine that reached conclusions that were significantly more open to prescribing opioids. Research into opioid use has changed little since the 2009 guidelines were written. Chou’s decision to alter course is unclear. He did not respond to a request for an interview."

The Annals of Internal Medicine, in its October 6, 2015 issue, presents guidance from an international board on the disclosure and management of conflicts of interest. While “direct financial” interests are easily defined, the article outlines “indirect” conflicts in the areas of academic advancement, clinical revenue streams, community standing, and scientific interest. Examples of such conflicts include “having published on a topic that expresses an opinion on the effectiveness of an intervention,” “gaining clinical income from the recommendation,” “leadership or board or committee memberships,” “involvement with an advocacy group,” and “personal convictions.”

http://www.asipp.org/FactSheet-AHRQ.pdf

 

[onewithpain]

When Chou was being paid by the American Pain Society (some would say indirectly by Purdue) he advocated for opioids. When Chou was being paid by the feds to find ways to decrease health care costs he advocates no opioids and no injections. There are valid arguments for and against almost anything. If you want to make a point you present arguments in your favor and let the opposition dig up their own arguments. It could be that Chou's opinion flip flops but when his opinion reflects his change in employer then you gotta wonder.

 

[Ligament]

Does Chou treat patients? He almost got spinal injections eliminated in Washington State with very biased meta analysis reports.

 

[bedrock]

Does Chou treat patients? He almost got spinal injections eliminated in Washington State with very biased meta analysis reports.

I would love it if someone ran that guy out of medicine. He's a hired gun with no morals who is ruining patients lives.

 

[101N]

You are tooo funny

 

[drusso]

I would love it if someone ran that guy out of medicine. He's a hired gun with no morals who is ruining patients lives.

The very least anyone could do would be to notify people of his ideological peculiarities.

http://www.professorwatchlist.org/

 

[onewithpain]

During his talk Chou said that he does still see patients but has limited hours. Based on the case that he presented he still does what he says we shouldn't be doing by prescribing opioids first without a clear diagnosis and without trying other treatment options. He said that he would be seeing the patient again and would see how the patient did with his proposed taper.

The frustrating thing is that I always felt that we as doctors are supposed to be advocates for our patients. Chou is worse than an IME or case reviewer for the insurance companies in that he searches for reviews that argue that everything that we do is ineffective and supplies these carefully selected opinions so that they can be used to deny treatment and save money. We can do a contrasting search and find studies that argue for the effectiveness of our treatments, but after sending a few of those to the insurance companies in response to their denials I realize that they don't care about other views. If Chou says it doesn't work then they have an expert who supports their argument and they are not paying for it. If Chou thought that he had an approach that worked better then I could see his argument that we shouldn't be spending money on injections, and many of us already would argue that other options should be exhausted before we resign patients to COT. But from what Chou is saying he is still starting with opioids. Now that he has created a monster the patient will express discontent and request a referral elsewhere and Chou will probably send him to Sibell. Then the poor guy will finally get an SI joint injection but will still hurt due to opioid induced hyperalgesia. During Chou's talk and those of all of the other speakers that day the objection to opioids was overdose and abuse. No one mentioned that more than short term use leads to increased pain which makes opioids bad medicine. None of this is new, it's just the swing of the pendulum as they try to save money. I hope that someday the pendulum will swing to where they value an accurate diagnosis and prompt appropriate treatment as that might also save money.

 

[101N]

"The frustrating thing is that I always felt that we as doctors are supposed to be advocates for our patients."

Here is where you lost me, and probably Roger as well. Most working-aged chronic pain patients don't know - or want - to
what is actually good for their health. They want easy solutions to their problem, i.e., a pill, an injection, a law suit, a disability claim.
You can't, in good conscientious, advocate for that. Look at the big three diagnoses that we see, cLBP, HA, & FMS. These are conditions
that shouldn't be disabling and we shouldn't encourage the mind set that they are. I think IPM as it's currently practiced perpetuates
pain and dysfunction rather than trying to treat it. We - most of us - have but two arrows in our quiver, injections and opioids, and
neither of them work for the vast majority of working-aged people with CNP. I see that, Roger see it, and lots of savvy internists and
family practitioners do as well.

We are living in an era of a fake pain epidemic and we've all participated in it just like we have in the opioid epidemic. But now we
are waking up. Continuing business as usual isn't working for patients or for the the well being of the country. The opioid 'pendulum'
is no more of a pendulum than the thalidomide pendulum, or the Vioxx pendulum, or the quinine pendulum. It was a mistake. As
was the claim that there a 1/3rd of our population is in chronic pain. We - and Pharma - have been the beneficiaries of a 30 yr effort
to medicalize suffering and neurosis. That's not Roger talking, it's one of us.

 

[lobelsteve]

Most of what i see is not clbp, ha, fms.

Thats little of what i see. something happened during your career to steer you down this path. come visit ligament, drusso, ampa, or me for just 2 days. maybe we can find your mojo.

 

[drusso]

During his talk Chou said that he does still see patients but has limited hours. Based on the case that he presented he still does what he says we shouldn't be doing by prescribing opioids first without a clear diagnosis and without trying other treatment options. He said that he would be seeing the patient again and would see how the patient did with his proposed taper.

The frustrating thing is that I always felt that we as doctors are supposed to be advocates for our patients. Chou is worse than an IME or case reviewer for the insurance companies in that he searches for reviews that argue that everything that we do is ineffective and supplies these carefully selected opinions so that they can be used to deny treatment and save money. We can do a contrasting search and find studies that argue for the effectiveness of our treatments, but after sending a few of those to the insurance companies in response to their denials I realize that they don't care about other views. If Chou says it doesn't work then they have an expert who supports their argument and they are not paying for it. If Chou thought that he had an approach that worked better then I could see his argument that we shouldn't be spending money on injections, and many of us already would argue that other options should be exhausted before we resign patients to COT. But from what Chou is saying he is still starting with opioids. Now that he has created a monster the patient will express discontent and request a referral elsewhere and Chou will probably send him to Sibell. Then the poor guy will finally get an SI joint injection but will still hurt due to opioid induced hyperalgesia. During Chou's talk and those of all of the other speakers that day the objection to opioids was overdose and abuse. No one mentioned that more than short term use leads to increased pain which makes opioids bad medicine. None of this is new, it's just the swing of the pendulum as they try to save money. I hope that someday the pendulum will swing to where they value an accurate diagnosis and prompt appropriate treatment as that might also save money.

@onewithpain, you hit the nail on the head. I used to see some of his patients. I don't know if he would know how to do a competent MSK exam or localize a neurological lesion. Still, the fundamental problem with Roger intersects at intellectual dishonesty, unprofessionalism, and COI. He has demonstrated by his own behavior the capacity to be cognitively cuckolded by whomever is writing a check or selling a population-health ideology that favors his mode of practice. He's an agent for a broader movement that seeks to repackage pain as a character deficit. I can't think of a single thing he's done to advance IPM in the interest of patients.

Read this:
http://healthydebate.ca/opinions/he...are-we-blind-to-our-own-conflicts-of-interest

 

[101N]

giggling "I can't think of a single thing he's done to advance IPM in the interest of patients."

 

[onewithpain]

I was going to retract my last post as I was feeling a little whiny last night after an extra glass of wine with dinner. It was good dinner, ribs with mole dry rub and the "2 elephants" wine from Costco.

I have many arrows in my quiver and one of them is not opioids. Everyone else is happy to prescribe opioids and I am not willing to set myself up for Chou-esq referrals. My #1 arrow is education. Many of my patients are happy after I explain that they don't have a tumor but rather an expected result of degeneration. #2 is compassion. I do feel the pain and have benefitted from RFA myself which allows me to run and swim and bike on a daily basis and I know that if I don't keep moving then I suffer. I know that the pain is no excuse for disability and in my 10 years in practice have not agreed with 1 disability application but have suggested retraining for many and have frequently argued that an OTJ injury that caused acute pain was followed by SAIF's refusal to treat which caused chronic pain. I go back to #1 and demonstrate for the patients how they can function with degeneration and how maintaining good posture and body mechanics can help control their pain. I don't get paid for PT but I end up doing a lot. I am more than happy to hear the patient say that they are able to control their pain without injections, and that they know that if it progresses then they can come back. I can and do in good conscience advocate for this.

I also listen to feedback from my patients and from my referral sources. Their is an amazing variation in pain specialists in this region. One who can remain unnamed is said to have never met a patient that he liked and is said by the referring providers to almost guarantee a bad outcome and is known by the OR staff where he has worked as the screamer. Others demonstrate the evolution of the financial structure of a pill mill by making their money on MS UDS. Most are trying hard to advocate for the patients, not by doing whatever the patient wants but by going through the process of good medicine.

Many patients present as if they are shooting for pills and disability and this is because of what they see in our society. There was a good article in Nat Geo this month with the cover suggesting that it was about faith healing. In the article is described a study in which they provided a subject with a painful stimulus. Prior to the stim they showed the subject a video of others receiving the same stim. If the video showed others in severe pain then the subject felt severe pain. If the video showed the others responding as if pain was minimal then the subject felt minimal pain. We live in a society in which the most visible others are responding as if they were experiencing severe pain and they are getting disability benefits for minor pathology. Our choices appear to be; label them all as fakers and druggies and dismiss them, or try to tackle the problem, first one patient at a time, by educating the patients and providing medically sound treatment options, and eventually propagating this by educating referring providers and the community in general. Those providers who choose the first are perceived to be dishonest or to have lost their mojo. It is hard to imagine how they could enjoy their work and this may be reflected by a flip flop in attitude or by repeatedly changing practice location. I think that visiting Lobel or others is a great suggestion. Grab a sixer and everybody shout together Roadtrip!!! Maybe we can get Chou to come along.

 

[Papa Lou]

I agree that Chou and 101N see a very specific patient population which overall sucks and BENEFITS from the decisions they are discussing. I am happy a stance is being taken to eliminate to fake pain patient complete bs that goes on and reduce opioids.

That's not all patients. Many many people need the kind of IPM I do which is education, physical therapy, reduction in opiods discussed every visit, injections to get them up and moving. What's deficient in that? Well I'll tell you the only deficiency is in my ******* wallet. This is no way to make a living! I did better with anesthesia. They pay very little for injections and very little for good care. So it's all about volume. Volume patients means low level decision making, which means pills. And UDS with it. But don't get confused and think most of these people have fake pain and just need pain psych. It's a mixture. And not all medicaid have all psych issues, that's presumptious and insulting. They are actually human beings too, and can have real pain like the commercially insured can have real pain (or need psych). What they need to do to solve the problem is capitate pain management. Problem solved. We all make money keeping the pain patients "healthy." We screw up and we're off capitation and out of the system.

 

[onewithpain]

Without any experience working with a capitated rate I am leery but was willing to try when my local OHA director suggested it. When they announced that they would not cover injections I asked, if I was seeing their patients under a capitated rate agreement then would I not be able to perform injections if I thought that was best. They still haven't responded to the question.

I expect that I will eventually see OHA patients on a capitated rate agreement. I have suggested that their patients try readily available community programs for CBT, weight loss, smoking cessation, PT, oral health, ... We can provide scheduling and guidance and individual assistance. This would ideally happen before the patient is resigned to COT. OHA has stated clearly that they do not want the pain specialists prescribing opioids as they feel that the pain specialists are the ones who are at fault for exorbitant doses. This seems a little twisted as it is the patients who are receiving exorbitant doses that are referred to pain specialists, but I don't mind that restriction. Trying to start this program has met with surprising resistance as the PCPs insist that they are comfortable prescribing 8 Norcos/day and would only refer the patients who request more.

 

[101N]

We've had some pretty serious discussions of pain management in the OHA/Medicaid population on
the private forum. We pretty much all agreed that it is hard, thankless work that not many want to do it.
It's a stop-loss model of care that's based on harm and cost reduction, not income generation. By and large,
IPM salaries are high enough that they probably aren't interested in being involved in this type of care.

 

[drusso]

Without any experience working with a capitated rate I am leery but was willing to try when my local OHA director suggested it. When they announced that they would not cover injections I asked, if I was seeing their patients under a capitated rate agreement then would I not be able to perform injections if I thought that was best. They still haven't responded to the question.

I expect that I will eventually see OHA patients on a capitated rate agreement. I have suggested that their patients try readily available community programs for CBT, weight loss, smoking cessation, PT, oral health, ... We can provide scheduling and guidance and individual assistance. This would ideally happen before the patient is resigned to COT. OHA has stated clearly that they do not want the pain specialists prescribing opioids as they feel that the pain specialists are the ones who are at fault for exorbitant doses. This seems a little twisted as it is the patients who are receiving exorbitant doses that are referred to pain specialists, but I don't mind that restriction. Trying to start this program has met with surprising resistance as the PCPs insist that they are comfortable prescribing 8 Norcos/day and would only refer the patients who request more.

@onewithpain, you can be PM me. I'll tell you my experience with OHA/CCO bureaucrats has been that they don't care about science and the system is a "closed shop" except for large health networks, FMQHC's, and community mental health. Don't be fooled: The medical directors and policymakers only care about money and not patient care. It's a twisted, collectivist, one-size-fits-all population health mind-set that you're up against.

 

[lobelsteve]

If you guys would get together and refuse their nonsense the problem goes away until they actually want our help. let admin and pcps handle this mess.

 

[onewithpain]

drusso; I will PM you. Any experience with OHA will help me prepare for going into the lion's den.

101N; that is why this has taken me so long. Although I don't have the luxury of a nice salary, even dealing with decreasing reimbursement I am better off ignoring OHA. But with decreasing reimbursement I am looking for other options. In addition to capitated rates, OHA offers grants up to 100k/year and they have offered to help fund my office staff. At the end of the year you get a lump sum from them based on how many of their patients you have treated so that your reimbursement ends up being about double what Medicare pays. The delay comes from their attempts to take my program proposal and revise it into a form that I don't think is good medicine. Every time they do that I tell them that I have a good day job and don't need their offer.

 

[SeniorWrangler]

I see a lot of headache patients and some of them get a lot of benefit from IMS, GON blocks, SPG blocks, etc.,. but ONLY in conjunction with serious medication managment and lifestyle changes.
You shouldn't do one without the other IMO (or, more sustainably, do the blocks while someone else like a neurologist does the other stuff), it's not going to be very beneficial. And doing blocks that don't help anyone is part of what created the problem we are all talking about.

 

[101N]

I see a lot of headache patients and some of them get a lot of benefit from IMS, GON blocks, SPG blocks, etc.,. but ONLY in conjunction with serious medication managment and lifestyle changes.
You shouldn't do one without the other IMO (or, more sustainably, do the blocks while someone else like a neurologist does the other stuff), it's not going to be very beneficial. And doing blocks that don't help anyone is part of what created the problem we are all talking about.

Interesting. IMO all neurologists who treat migraine with BTX should use the FSQ to identify the comorbid FMS. There is a huge comorbidity between the two & they are intentionally ignoring it.
I am fairly certain that what Levy found below is equally true with migraineurs in neurology clinics (and with us in back pain clinics).


Clin Exp Rheumatol. 2016 Mar-Apr;34(2 Suppl 96):S120-4. Epub 2016 Apr 6.
The impact of concomitant fibromyalgia on visual analogue scales of pain, fatigue and function in patients with various rheumatic disorders.
Levy O1, Segal R2, Maslakov I3, Markov A3, Tishler M3, Amit-Vazina M3.
Author information

Abstract
OBJECTIVES:
To evaluate the impact of concomitant fibromyalgia on the rating of pain, fatigue, and dysfunction, in patients with various rheumatic disorders.

METHODS:
A cross-sectional study was carried out in a hospital-based rheumatology unit. Standard clinical and laboratory data were obtained and all patients completed questionnaires on pain, fatigue, and daily function. The rate of concomitant fibromyalgia was estimated using the 1990 American College of Rheumatology (ACR) classification criteria for fibromyalgia and the analysis concentrated on visual analogue scales (VAS).

RESULTS:
Six hundred and eighteen visits of 383 patients with inflammatory as well as non-inflammatory rheumatic disorders were analyzed. Concomitant fibromyalgia was noted in 74 patients (23% of the cohort). Patients with rheumatic diseases and concomitant fibromyalgia had significantly higher mean VAS scores for pain, fatigue, and function (79±17, 81±18, 80±18, respectively) as compared to patients who had no features of fibromyalgia (47±28, 50±29, 44±30 respectively; all p values <0.001). The scores reported by patients with rheumatic diseases and concomitant fibromyalgia were similar to the scores obtained from patients with primary FM.

CONCLUSIONS:
Concomitant FM is common both among patients with inflammatory and patients with non inflammatory rheumatic disorders. Concomitant FM has a remarkable impact on the severity of symptoms and, moreover, patients with concomitant FM exhibit extreme and significantly distinct levels of pain and fatigue which is as severe as that reported by patients with primary FM. It seems that fibromyalgic features dominate and become the main cause of morbidity in rheumatological patients with concomitant FM.

 

[lobelsteve]

What about those with migraines and no body pain, no Psych issues? Just Imitrex, Excedrin, and closet floors.

 

[lonelobo]

The very least anyone could do would be to notify people of his ideological peculiarities.

http://www.professorwatchlist.org/

Why don't you just have the Jack Boots look into them?

 

[DrCommonSense]

Likely pointless to cover opioids or interventions for 90% of those on medicaid. What they really need to cover is visits with pain psychology for these patients.

Again, yet another reason not to accept medicaid. I never will again see medicaid in any state as a pain physician.

Pain psychologist won't work either.

I have NEVER seen Medicaid patients improve from that or become productive citizens after a few "CBT" visits. They usually won't even go and skip out most of the time.

 

[DrCommonSense]

Interesting. IMO all neurologists who treat migraine with BTX should use the FSQ to identify the comorbid FMS. There is a huge comorbidity between the two & they are intentionally ignoring it.
I am fairly certain that what Levy found below is equally true with migraineurs in neurology clinics (and with us in back pain clinics).


Clin Exp Rheumatol. 2016 Mar-Apr;34(2 Suppl 96):S120-4. Epub 2016 Apr 6.
The impact of concomitant fibromyalgia on visual analogue scales of pain, fatigue and function in patients with various rheumatic disorders.
Levy O1, Segal R2, Maslakov I3, Markov A3, Tishler M3, Amit-Vazina M3.
Author information

Abstract
OBJECTIVES:
To evaluate the impact of concomitant fibromyalgia on the rating of pain, fatigue, and dysfunction, in patients with various rheumatic disorders.

METHODS:
A cross-sectional study was carried out in a hospital-based rheumatology unit. Standard clinical and laboratory data were obtained and all patients completed questionnaires on pain, fatigue, and daily function. The rate of concomitant fibromyalgia was estimated using the 1990 American College of Rheumatology (ACR) classification criteria for fibromyalgia and the analysis concentrated on visual analogue scales (VAS).

RESULTS:
Six hundred and eighteen visits of 383 patients with inflammatory as well as non-inflammatory rheumatic disorders were analyzed. Concomitant fibromyalgia was noted in 74 patients (23% of the cohort). Patients with rheumatic diseases and concomitant fibromyalgia had significantly higher mean VAS scores for pain, fatigue, and function (79±17, 81±18, 80±18, respectively) as compared to patients who had no features of fibromyalgia (47±28, 50±29, 44±30 respectively; all p values <0.001). The scores reported by patients with rheumatic diseases and concomitant fibromyalgia were similar to the scores obtained from patients with primary FM.

CONCLUSIONS:
Concomitant FM is common both among patients with inflammatory and patients with non inflammatory rheumatic disorders. Concomitant FM has a remarkable impact on the severity of symptoms and, moreover, patients with concomitant FM exhibit extreme and significantly distinct levels of pain and fatigue which is as severe as that reported by patients with primary FM. It seems that fibromyalgic features dominate and become the main cause of morbidity in rheumatological patients with concomitant FM.

You are claiming there is a "fake pain epidemic" yet are pushing the "disease" called "Fibromyalgia" which would be the number 1 "fake disease" out there for pain patients?

I really don't ever understand your argument. If its all "fake", why spend money on Lyrica and all these expensive big pharma drugs to alleviate it?

 

[bedrock]

Pain psychologist won't work either.

I have NEVER seen Medicaid patients improve from that or become productive citizens after a few "CBT" visits. They usually won't even go and skip out most of the time.

Very few Medicaid patients ever improve on opioids or after IPM procedures, either.

I'll still offer psych first, if they don't follow through then all future treatment of their pain should be withheld.
These people need to take personal responsibility for their lives.

 

[DrCommonSense]

Very few Medicaid patients ever improve on opioids or after IPM procedures, either.

I'll still offer psych first, if they don't follow through then all future treatment of their pain should be withheld.
These people need to take personal responsibility for their lives.

Correct.

Very few improve after ANYTHING on Medicaid.

Surgery, IPM, acupuncture, Chiro, CBT, etc don't "improve" these people to any functional extent.

Neither does any medication such as Lyrica or Cymbalta.

So why fund anything?

You think any of the gibberish 101N talks about or Chou would ever fix any of them?

 

[bedrock]

Correct.

Very few improve after ANYTHING on Medicaid.

Surgery, IPM, acupuncture, Chiro, CBT, etc don't "improve" these people to any functional extent.

Neither does any medication such as Lyrica or Cymbalta.

So why fund anything?

You think any of the gibberish 101N talks about or Chou would ever fix any of them?

The challenge with medicaid is that I think 10% of these patients are quasi legit and are on medicaid because they are the working poor, such as a hotel maid, etc. I still think there is some hope for that 10%. I don't personally accept medicaid any longer because the other 90% are crazy wastes of skin that shouldn't have access to opioids, IPM, etc. I think they should only get medical care for major trauma, because they just waste resources otherwise.

However, I have seen CBT and chiro, cymbalta, and sleep hygiene help some of the 10% with spinal DDD, after some counseling by me that there is no procedure or med to magically fix them.

I do think that 101N is crazy and unrealistic with his gibberish, but in fairness to him, seeing medicaid patients warps the mind and removes all joy from life, which is why I don't see Medicaid any longer.

 

[DrCommonSense]

The challenge with medicaid is that I think 10% of these patients are quasi legit and are on medicaid because they are the working poor, such as a hotel maid, etc. I still think there is some hope for that 10%. I don't personally accept medicaid any longer because the other 90% are crazy wastes of skin that shouldn't have access to opioids, IPM, etc. I think they should only get medical care for major trauma, because they just waste resources otherwise.

However, I have seen CBT and chiro, cymbalta, and sleep hygiene help some of the 10% with spinal DDD, after some counseling by me that there is no procedure or med to magically fix them.

I do think that 101N is crazy and unrealistic with his gibberish, but in fairness to him. seeing medicaid patients warps the mind and removes all joy from life, which is why I don't see Medicaid any longer.

101N is a joke that clearly doesn't work in the real work (kind've like Rodger Chou) and makes up interesting stories about how to "treat" patients with no evidence of success or cost savings to probably just get money from some govt agency that fraudulently conducts "efficiency" studies that save literally no money but cost millions in "consultant" fees.

Its a total scam that hopefully Trump puts an end to in the future by first defunding what is left of the fraud that is AHRQ.


The vast majority of Medicaid patients don't improve due to SECONDARY gain issues regardless of ANY treatment.

Ergo, by 101N "logic", nothing should be done for the Medicaid population at all since nothing actually works on them to get them more functional to "work" or even decrease their pain in general for 90+%.

I agree that the only Medicaid people that would benefit are the ones who WANT TO WORK in the future and just have a lower paying job at the moment whereby they require Medicaid. Those are the ones I will see obtain real world improvement due to lack of secondary gain.

I wouldn't have a problem with eliminating ALL medical care outside of catastrophic care for >90+% of the Medicaid population.

However, hypocritically, clowns like Rodger Chou are still supporting paying for Chiro, Acupuncture, very expensive medications such as Lyrica, etc. that show ZERO benefit for >95% of the Medicaid population despite costing Billions of dollars for these "treatments".

That is where I have a problem with this stuff.

 

[Ducttape]

question... in which neck of the woods are you getting Medicaid coverage for chiropractic services or acupuncture? obviously, not where i am. Lyrica, maybe after failing all other meds and prior auth...

do you actually take Medicaid patients, and if you do, what percentage of your population is Medicaid? cause methinks you are blasting Medicaid when you don't have real world experience with these patients.

I wouldn't have a problem with eliminating ALL medical care outside of catastrophic care for >90+% of the Medicaid population.

fyi, the key imo with Medicaid patients is to reduce the suffering, not the level of pain, associated with chronic pain in a safe (and inexpensive) manner, while encouraging them to return to functionality. I think it is inherently biased to presume that Medicaid patients don't have pain, but that doesn't mean they should be exposed to dangerous treatments that are costly and unlikely to provide any benefit - ie IPM - for the most part - or substances with addictive potential.

and it baffles my mind why any private practice would take anything more than the token Medicaid patient, 1 in a million for example...

 

[DrCommonSense]

question... in which neck of the woods are you getting Medicaid coverage for chiropractic services or acupuncture? obviously, not where i am. Lyrica, maybe after failing all other meds and prior auth...

do you actually take Medicaid patients, and if you do, what percentage of your population is Medicaid? cause methinks you are blasting Medicaid when you don't have real world experience with these patients.


fyi, the key imo with Medicaid patients is to reduce the suffering, not the level of pain, associated with chronic pain in a safe (and inexpensive) manner, while encouraging them to return to functionality. I think it is inherently biased to presume that Medicaid patients don't have pain, but that doesn't mean they should be exposed to dangerous treatments that are costly and unlikely to provide any benefit - ie IPM - for the most part - or substances with addictive potential.

and it baffles my mind why any private practice would take anything more than the token Medicaid patient, 1 in a million for example...

In Oregon, they have added "Chiropractic sessions" and "Acupuncture" as "alternative treatment options" that OREGON MEDICAID PAYS FOR. Look it up.

I have plenty of experience with Medicaid patients actually. I have literally NEVER seen one go back to work/improve function or even reduce pain much when prescribing them Lyrica at 700/month.


So you have evidence that expensive drugs like Lyrica provide functional benefit for the vast majority of Medicaid patients at 700 dollars/month (far more than IPM costs)?

Lyrica is quite "dangerous" as well when you read the huge side effect profile of the drug with extremely high costs.

My argument is that from "EBM", since literally NOTHING has been proven to improve their functionality/improve them getting to work/etc, they should pay for nothing in the interests of "efficiency".

Understand?

 

[DrCommonSense]

Interesting. IMO all neurologists who treat migraine with BTX should use the FSQ to identify the comorbid FMS. There is a huge comorbidity between the two & they are intentionally ignoring it.
I am fairly certain that what Levy found below is equally true with migraineurs in neurology clinics (and with us in back pain clinics).


Clin Exp Rheumatol. 2016 Mar-Apr;34(2 Suppl 96):S120-4. Epub 2016 Apr 6.
The impact of concomitant fibromyalgia on visual analogue scales of pain, fatigue and function in patients with various rheumatic disorders.
Levy O1, Segal R2, Maslakov I3, Markov A3, Tishler M3, Amit-Vazina M3.
Author information

Abstract
OBJECTIVES:
To evaluate the impact of concomitant fibromyalgia on the rating of pain, fatigue, and dysfunction, in patients with various rheumatic disorders.

METHODS:
A cross-sectional study was carried out in a hospital-based rheumatology unit. Standard clinical and laboratory data were obtained and all patients completed questionnaires on pain, fatigue, and daily function. The rate of concomitant fibromyalgia was estimated using the 1990 American College of Rheumatology (ACR) classification criteria for fibromyalgia and the analysis concentrated on visual analogue scales (VAS).

RESULTS:
Six hundred and eighteen visits of 383 patients with inflammatory as well as non-inflammatory rheumatic disorders were analyzed. Concomitant fibromyalgia was noted in 74 patients (23% of the cohort). Patients with rheumatic diseases and concomitant fibromyalgia had significantly higher mean VAS scores for pain, fatigue, and function (79±17, 81±18, 80±18, respectively) as compared to patients who had no features of fibromyalgia (47±28, 50±29, 44±30 respectively; all p values <0.001). The scores reported by patients with rheumatic diseases and concomitant fibromyalgia were similar to the scores obtained from patients with primary FM.

CONCLUSIONS:
Concomitant FM is common both among patients with inflammatory and patients with non inflammatory rheumatic disorders. Concomitant FM has a remarkable impact on the severity of symptoms and, moreover, patients with concomitant FM exhibit extreme and significantly distinct levels of pain and fatigue which is as severe as that reported by patients with primary FM. It seems that fibromyalgic features dominate and become the main cause of morbidity in rheumatological patients with concomitant FM.

Most Rheumatologists in Canada don't even believe Fibromyalgia is a real disease and believe its just a psychosomatic issue.

http://www.prohealth.com/library/showarticle.cfm?libid=16965

Considering there are zero lab tests, zero imaging tests, etc with only very vague clinical "symptoms", maybe we shouldn't be spending billions of dollars to "treat" this "disease" with very expensive drugs such as Lyrica that have many side effects.

Oh wait, I forgot, for some reason, this "disease" you seem to be invested in keeping yet downplay actual anatomic problems that can be found on MRIs, etc.

Even though i do agree that MRI findings can be deceiving in terms of being a pain generator between patients, AT LEAST THERE IS OBJECTIVE EVIDENCE that can be found for these anatomic problems unlike "Fibro"

 

[Ducttape]

In Oregon, they have added "Chiropractic sessions" and "Acupuncture" as "alternative treatment options" that OREGON MEDICAID PAYS FOR. Look it up.

I have plenty of experience with Medicaid patients actually. I have literally NEVER seen one go back to work/improve function or even reduce pain much when prescribing them Lyrica at 700/month.


So you have evidence that expensive drugs like Lyrica provide functional benefit for the vast majority of Medicaid patients at 700 dollars/month (far more than IPM costs)?

Lyrica is quite "dangerous" as well when you read the huge side effect profile of the drug with extremely high costs.

My argument is that from "EBM", since literally NOTHING has been proven to improve their functionality/improve them getting to work/etc, they should pay for nothing in the interests of "efficiency".

Understand?

1. Im sorry you have not had people go back to work. I have.... I dont start them on people who are not working. I do have people that have stayed at work when they have been given medication, although typically not Lyrica (cause I hate prior auths). and if they cant stay at work, they come off of the expensive drugs.
2. there is more EBM that suggests that alternative therapies such as yoga, tai chi, resistance band training, cognitive behavioral therapy are more beneficial than opioids or expensive medications.

 

[DrCommonSense]

1. Im sorry you have not had people go back to work. I have.... I dont start them on people who are not working. I do have people that have stayed at work when they have been given medication, although typically not Lyrica (cause I hate prior auths). and if they cant stay at work, they come off of the expensive drugs.
2. there is more EBM that suggests that alternative therapies such as yoga, tai chi, resistance band training, cognitive behavioral therapy are more beneficial than opioids or expensive medications.

1) I never had anyone on Medicaid that doesn't work go back to work by being prescribed Lyrica or some Chiropractic care. People who WANT to go to work can improve but the vast majority of Medicaid don't want to improve. That is my experience.

2) I agree with this although how many Medicaid patients will want to go for those "therapies"? I have almost no success trying to send my Medicaid patients to our Behavioral specialists that are PHDs in the field. The only way to get them to go is to threaten to cut off their narcotics if they don't go for an assessment or further therapy sessions. Once opioids are stopped, I almost NEVER see them continuing with Behavioral therapy. I have NEVER seen any of them getting back to work due to CBT if they haven't been working already.