E5: Non-Opioid Healing Strategies

This is OnePath with Metrohealth, your toolkit for helping to combat the opioid epidemic as a member of the medical community with empathy, mindfulness, and a big-picture perspective. I’m Libbey Pelaia, educator within Metrohealth’s department of Opioid Safety. Thanks for joining us.

In the world of safer opioid prescribing and pain management, non-opioid, and even non-medication-based modalities of care, are a highly valuable option. MetroHealth’s pain and healing center, led in part by today’s guest, Dr. Chong Kim, was created to suit the vision of a multidisciplinary, comprehensive, and holistic approach to managing a patient’s pain: including consideration of a patient’s health, emotions, favorite activities, relationships, and work. A varied group of specialists work with the pain and healing center to help provide a diverse range of pain management options for patients.

Dr. Kim says that the interesting-- and difficult-- thing with pain is that there’s a subjective component beyond simply the physical experience of it. The mental component of pain is significant, and varies greatly from patient to patient.

CK: Any pain we address, whether it's an ankle sprain to a leg fracture or something acute, or just happened or something that's malingering, and we kind of explore anything and everything that exists. We try not to get focused on one treatment as be all end all for everyone.

CK: We use a lot of psychology and psychiatry, because there's an emotional and psychological component, which I think really helps the patient because it's overall wellbeing. Because we've all gone through it where something hurts, but if you're having a good day and it hurts, it's much more tolerable than you're having a really crappy day and you have all this stress at home and work. So we make sure that emotionally and psychologically, they get the support. And then we look at all the other interventional treatments for them, simple nerve blocks that are just diagnostic to therapeutic. Any of the minimally invasive procedures from simple spacers or neuromodulation devices. And then obviously, we use collaboration with a lot of the other specialties if they need a surgical solution. So anything and everything that exists, we try to provide.

The pain and healing center is also dedicated to being an accessible resource for patients.

I think that was the initial goal: how do we just allow patients to get in? Because ultimately, instead of trying to have them go jump through a bunch of hoops to see us, or be concerned are they getting seen by the right provider, we'll take care of that as long as they they're willing to come in. Some patients may get a little information sheet to fill out. It allows them to consolidate what they're coming in for. But again, if someone shows up, we'll see them, try to make it as easy as possible.

There's two ways the patient can come in and see us. We actually no longer require a referral. So if a patient calls, they can just go on the website, look up the number, call us, we'll see them

If they're already in the system and they've seen someone, they just can go online and just basically book an appointment, that's another way. And then obviously, there's a referral from whoever they normally see, whether it's primary care or specialists. If they're internal, it's done by computer. You just type the pain referral. And then if they're external, they just call us.

Because of the specific priorities of the pain and healing center, they’re able to provide a different level of care and attention to detail than what’s available in a primary care setting.

In a regular office setting for primary care physician, it's not that they don't want to do it or they can't do it if they really had to, it's just that in X number of time, when they're dealing with all the medical issues that typically come to it, pain becomes pushed down a little bit on their priority list. And then it becomes, Hey, go do this, except it's not the full, comprehensive assessment of it. And then the treatment options that are available, we were fully aware of it as well as we utilize it all the time.

And so I think it's just a better setting for us to basically oversee that component, especially in patients that have been suffering for a long time, that it is such a big part of their life that they get kind of a champion in their corner that's going to work with them and kind of, it's a process where first thing we can do is kind of educate them on what's going on and what the options are.

Health care's still a person to person relationship, so, I mean, I think we have made significant changes in the providers itself. So we've had a lot of new additions, a lot of new services. So I think the providers that are currently here are interested in the longterm outcome. That's not a quick, Hey, let's just do this and hopefully it works. It's, you know what, it's a work in progress and we're in it for the long haul, as long as they were willing to let us be part of it.

Dr. Kim says that the caregivers at the pain and healing center begin with the very basics when speaking with a new patient, following their vision of using a comprehensive picture of a patient’s day-to-day experience in creating a pain management plan.

We start with the simplest, Hey, how's your nutrition? How's your sleep pattern? How's your exercise program? How's your stress level? Do you have any bad habits? Are you a smoker? Because that all impacts their overall health as well as their pain.

We do a lot of self-improvement, which is not the easiest, because we all know what we should do, but we try to reinforce that as a good starting point that they have to get involved in their care, that there may not be a magic pill or magic solution. It's a work in progress in terms of, we're just trying to get better and every day, if we can get better, in the long run, we'll be much better off because of that. We do a lot of physical therapy, home exercise programs, non-opiate medications. We try to kind of go into a mode where opioids may be appropriate for certain situations, but over the past 30 years we've seen that it doesn't really work for everybody and it's definitely not something that doesn't come with significant risks.

No matter what level of pain a patient is dealing with, if opioids are going to be used, they have to be used in the right manner and with all precautions built-in to prevent a negative outcome. The pain and healing center pays a LOT of attention to mindful opioid use.

So, somebody's had back surgery in the hospital, we need to control their pain and we try to use all the modalities we have, but ultimately pain medication is one of them. And I think those are easy except one area that the medical society has failed is there should be a nice educational process to the patient as a way to list their family of, Hey, how the pain is going to get controlled as well as a taper and exit plan of what they're going to do, so a patient's not clueless in terms of, they're just getting this and then all of a sudden stop. It's more of a, Hey, we know your pain should last for this amount, we're going to do our best to modify it with all the treatment options, including pain medications, here's the risks with it. We need you to be understanding of your role in taking these medications and then to keep us abreast of what's going on, because if you have any issues that can be addressed, but if we address it early, it doesn't become uncontrollable, a chronic condition.

Sub-Acutely is probably where we're probably getting more involved, where we do a lot of screening in terms of risk assessment. Now, there's simple ones that have been validated to some degree. They're not perfect. In terms of chronic is where we probably did the most screening or assessments before we actually continue somebody. We actually get a full pain, psychology evaluation for risk assessment. And it's nothing more than just to see if somebody is predisposed to being addicted or they pick up some other conditions that we're not seeing because they're independent screeners.

We do a lot of other oversight in terms of, are you at risk for something else? Although the opiods itself may not be their risk. Do you have sleep apnea? Because they've shown that if you have sleep apnea, you take pain medications, you may have a worse outcome in terms of poor sleep, energy, heart problems, blood pressure issues, so forth. We also screened for making sure that all the medications that are taken are not inappropriate interacting. So if you're on a sleep aid or you're taking anxiety medications with pain medications, they found there's increased risk of a bad outcome. So we do that screening. And then we do just simple things like, is your energy low because you have hormone problems secondary to you being on chronic opioids? So there's a lot of screening we do in a chronic setting, but acutely, I think we don't do as much because we have to address the acute pain issue.

Dr. Kim shared that he believes the goals of the department of opioid safety and those of the pain and healing center go hand-in-hand.

I think for a while, people always wondered if it was an issue. And I think, in my opinion, it's actually the opiate safety really supports us in what we're trying to do and we support them in what they're trying to do, because we know pain's an issue. We know opioids have been a big part of the treatment algorithm, probably too much and maybe inappropriately. And because of it, I think we have to be accountable for some of the issues that exist in society now. That's why we're trying to get involved in the acute pain component, because that may be all it needs for somebody to do inappropriately or do poor followup for us to lose control of a patient that should not have gotten that and they had nothing to do with it, it's just that's the way they were physiologic or just genetically made up.

Perhaps the most important aspect of the Pain and Healing center is its dedication to being an ever-evolving an ever-improving entity. In staying ahead of problems before they arise, the pain and healing center is able to help create a new culture of proactive caregiving in the highly personal world of pain.

We are getting involved in the inpatient setting, discharge setting. We recently started a component where we're helping our primary care providers that have been either inheriting some of these patients that there's somebody who used to practice has left and they said, Hey, this is what I've been doing, continue it. Or somebody retires and patient's like this is what I've been getting for 20 years. We've actually started a referral source for them to just reach out to us. And we'll just take those patients over to help them out in terms of making sure it's appropriate, do the screening or even modify it and then add other treatments, hopefully to improve the overall quality of life. Because at the end of the day, we're not really that concerned about just the pain score anymore.

It's probably the quality of life and improved function that we're looking for. So the services we're providing, the goals, the way we measure it, are different. Where before I think they were just concerned about what's your pain score, you take something, did it get better? And we found that it's all subjective or it's not as relevant if you're not actually experiencing the improvement in terms of what you're living is. So that's what we're working on.

Next time on One Path…

We look into the world of Emergency Department Medical Assisted Treatment.

OnePath with Metrohealth is a production of Evergreen Podcasts, produced, written, and engineered by Hannah Rae Leach and mixed by Sean Rule-Hoffman. Special thanks to Mike Tobin, Karolyn Tibayan, Joan Papp, Joya Riffe, and the entire Department of Opioid Safety in making this show possible.