Blog

Nadine Blair knows pain.

The 61-year-old Vancouver resident has fibromyalgia, migraines and osteoarthritis. When they all flare up, Blair is left writhing in pain.

For many years, Blair relied on medication. She had different physicians for each condition. She had various dosage levels of opioid medications for her migraines, osteoarthritis and fibromyalgia.

Yet, the pain started taking over her life.

“It was slow,” she said. “Then suddenly you wake up one morning and wonder, ‘What happened to my life?’”

Blair is one of the millions of Americans in pain.

Chronic pain affects 116 million Americans. That’s more than one-third of the population and more than heart disease, diabetes and cancer combined, according to the Institute of Medicine.

In Washington state, at least 1.7 million people, or one-quarter of the population, report issues with pain, according to the American Pain Foundation. Locally, the number of residents dealing with chronic pain could easily be in the tens of thousands.

Yet as the pain population grows, patients’ access to treatment deteriorates, said Elin Björling, Washington state policy specialist and action network manager for the Western region of the American Pain Foundation. Those with limited means have even fewer options, she said.

A survey conducted by the foundation in September revealed that 70 percent of Washington health clinics do not treat patients with chronic pain. Ten percent of community clinics treat pain patients but don’t provide opioid therapy for chronic pain.

Björling and other advocates for pain patients worry new state rules for prescribing pain medication will make finding a physician more difficult.

“We are already in a state of crisis in terms of access,” she said. “This will feed fuel to the fire.”

Pain rules

Last year, Washington lawmakers passed a bill to implement stricter rules for prescribing pain medication.

The rules apply only to the management of chronic pain not caused by cancer. None of the rules apply to palliative (last year of life) care, hospice or end-of-life care. They also don’t apply for management of acute pain from an injury or surgical procedure.

The new rules require patient evaluations, a written treatment plan and a written agreement for care. The rules also call on physicians to complete at least four hours of training before prescribing long-acting opioids or methadone.

One of the biggest changes — and the one raising the most concern among pain patient advocates — is the requirement for a pain specialist consultation. Prescribers with a patient who reaches an established threshold (120 mg of a morphine equivalent per day) must seek a pain specialist consultation under the new rules. Some exemptions do apply.

The rules go into effect for physicians and physician assistants on Jan. 2. For prescribers in other fields, the rules went into effect July 1.

The new rules are intended to reduce hospitalizations and deaths from opiate medications, not to improve pain care.

And that’s precisely the problem, said Jennifer Wagner, executive director of the Western Pain Society and director of clinical research at Pain Research of Oregon.

The state is facing two public health crises: prescription drug overdoses and addiction, and lack of access to pain care. The rules respond to the first crisis at the expense of the second, Wagner said.

Already some physicians have stopped accepting new patients with chronic pain and others have begun dropping pain patients.

Physicians fear the regulatory scrutiny and are confused by the new rules. Many also don’t feel knowledgeable enough to prescribe the pain medication and worry about causing addiction in patients, Wagner said.

In addition, pain patients require more time than most patients, yet the insurance reimbursement to physicians isn’t higher. Tack on the additional education and consultation requirements, and many physicians just decide against treating the patients, Björling said.

“There are some major barriers,” she said. “(The law) adds more barriers and red tape.”

Patients, no physicians

But lawmakers contend the rules aren’t to blame for physicians dropping patients.

“People are contacting my office about access problems, not about the bill, but about doctors unwilling to treat them,” said State Rep. Jim Moeller, D-Vancouver, who sponsored the legislation. “That has nothing to do with the bill at all. They’re using the bill as an excuse to get out of treating their patients, and I don’t understand why.”

Moeller, who has worked as an addiction counselor for more than 25 years, said he considers physicians who drop pain patients as failing to fulfill their Hippocratic oath.

Dr. Mimi Pattison, chair of the Medical Quality Assurance Commission, was on the committee that drafted the rules. The rules include what should be considered good practice, she said.

“If people are not going to follow the rules, which I think are a good standard of care, then I’m glad they’re not going to treat pain patients because I don’t think they’re going to do a good job,” Pattison said.

Whatever the reasons for dropping patients, Dr. Robert Djergaian is already seeing the fallout. Some local physicians have already dropped pain patients and referred them to PeaceHealth Southwest Medical Center’s new pain rehabilitation program, said Djergaian, director of physical medicine and rehabilitation at the medical center.

“I can’t help but believe that (the rules) will mean people will have less access,” he said.

Specialists shortage

In addition to primary care physicians dropping pain patients, advocates worry about the lack of specialists in the state.

Pain specialists already have big caseloads. As more and more primary care physicians stop treating chronic pain, more people will turn to pain specialists. The requirement to seek a pain specialist consultant will leave the limited number of pain specialists overwhelmed, Björling said.

“The seams are starting to tear and the capacity for everyone is at the brink of destruction,” she said.

The state committee took the shortage of pain specialists into consideration when writing the new rules, Pattison said.

The rules include a number of exemptions, she said. For example, physicians with 12 hours of continuing education in chronic noncancer pain, specifically in opioid prescribing, are exempt from the consultation, Pattison said.

The committee intentionally kept the bar high for pain specialists to prevent underqualified people from providing consultations, she said. The rules follow the American Board of Medical Specialties’ standards for pain specialists, Pattison said.

Alternatives to opiates

Another issue that has arisen from the new rules is the lack of reimbursement for alternative methods of pain management.

“Since it’s not a pain management law, it’s an opiate law, they’re hoping that patients would utilize other things in place of opiates, such as acupuncture or yoga,” Djergaian said. “The state of Washington and Labor and Industries doesn’t pay for those things.”

The state also recently limited physical therapy visits to eight per year for Medicaid patients. Most medical insurance doesn’t cover the alternative treatments but does cover opiates, Djergaian said.

The state wants to restrict opiate use but doesn’t offer tools for patients to self-manage their pain, he said.

“It requires a fair amount of work and resources to fill in the void that would be created by taking them off of opiates,” Djergaian said. “A lot of these patients don’t have the support to do that.”

The new pain rehabilitation program at PeaceHealth Southwest Medical Center aims to equip patients with those tools for self-management.

Blair, who has lived with chronic pain for several years, recently completed the medical center’s six-week program. The program consists of weekly meetings and includes physical therapists, psychologists and pain specialists.

Through the program, Blair learned relaxation techniques she uses twice a day to calm her mind and body and prevent the stress that triggered pain. She uses tricks to eliminate the negative self-talk that caused fear of pain and hampered her motivation. She has also resumed a regular exercise program, including time in the gym and the pool.

Blair is still on some medication to manage her fibromyalgia and osteoarthritis, but she’s been able to stop taking the narcotic medications. She went from having 15 migraines a month to just two. She’s planning vacations and has started ballroom dancing again.

“I think patients have to be responsible for their care, ultimately,” Blair said. “And that’s a challenge.”

For the first time, Blair said she has a comprehensive plan for her pain care.

Forming a pain society

The notion of comprehensive and collaborative pain care is spreading in Clark County.

In September, Wagner spoke to 83 local practitioners representing numerous disciplines who were interested in forming a Vancouver Pain Society. The local pain society will be modeled after the Pain Society of Oregon, which has members from multiple disciplines, including physicians, nurses, pharmacists, psychologists, chiropractors, acupuncturists, physical therapists and social workers.

The society will host monthly meetings with guest lecturers who speak on pain topics. In addition to the education, providers will have a forum to discuss pain management. Providers can network and learn from the success of others, said Shannon Wilson, who is involved in the effort and works as PeaceHealth Southwest’s spine care coordinator. Wilson is also an American Pain Foundation action network leader in Washington.

The next step, Wilson said, is to get the leadership group together and establish the society’s mission and infrastructure and plan meetings. The first meeting is scheduled for January.

The Vancouver Pain Society will be the first pain society in Washington state. So far organizers have received encouragement from local providers and political leaders who support the movement.

“I think it’s an excellent idea,” Moeller said. “It’s more than time.”

“We need to take a look at how we can best address it because it’s not going to go away,” he added. “By doctors throwing up their hands and saying, ‘I’m not going to deal with it anymore,’ that’s the wrong avenue.”

KARACHI – It is extremely important to assist physically-challenged individuals in achieving an independent, productive, and satisfying lifestyle and occupational therapists can play a key role to accomplish this goal, said health experts at a seminar held on Monday.
The seminar was organised by the Dow University of Health Sciences (DUHS) to commemorate World Occupational Therapy Day.
“Occupational therapists are urgently required in the country,” said Dr Nabeela Soomro, director of the Institute of Physical Medicine and Rehabilitation, DUHS. “They are the prerequisite for rehabilitation of the disabled as an occupational therapist also assists them in daily living activities at home like feeding, grooming, bathing, toileting, in returning to work and resuming community activities,” she elaborated.
Dr Soomro said that community-based rehabilitation (CBR) is a strategy employed for the rehabilitation, equalisation of opportunities and social integration of all people with disabilities.
“This, however, can be implemented through combined efforts of disabled people themselves, their families and communities, and the appropriate health, education, vocational and social services.”
DUHS Pro Vice Chancellor Prof Mohammad Umer Farooq, speaking as the chief guest of the event, said that occupational therapy is a healthcare profession that provides services to people, whose ability of everyday functions is disrupted by some disability, developmental problems, aging process, mental illness, or emotional problems.
“The profession has the potential to contribute significantly to the prevention and management of childhood disability in Pakistan,” he said. “It is estimated that more than 100 million people worldwide with disabilities can benefit from rehabilitation services.”
Prof Farooq, who is also a senior ENT surgeon, said that it is important to refer children to an occupational therapist as soon as it is evident that they have or are at risk of developing limitations in their development or independent functioning.
Other speakers on the occasion pointed out that the most commonly treated disabling conditions include stroke, arthritis, amputation, birth defects, mental retardation, head injury, spinal cord injury, depression, learning disabilities, drug alcohol abuse and physical disability.
Replying to questions by the participants of the programme, Prof Soomro said that the facilities available at the Institute of Physical Medicine and Rehabilitation, DUHS also focus on helping cerebral palsy patients achieves independence in all areas of their life.
“Occupational therapy for cerebral palsy patients can provide them with positive, fun activities to enhance their cognitive, physical, and fine motor skills and increase their self-esteem and sense of accomplishment,” she said.
“The goal of occupational therapy for cerebral palsy patients is to help them live as independently as possible.”
Later, the participants of the seminar visited clinics of occupational therapy to personally witness the services being offered by the Institute of Physical Medicine and Rehabilitation, DUHS.
On the occasion, adaptive equipment prepared the students, ADL equipment and positioning aids for cerebral palsy children were put on display.

Bogus policies, little centralized oversight and an increasingly elaborate network of fraud is permeating the workers’ compensation insurance market and sapping millions in state revenue, a House panel heard Tuesday.

But a workgroup said meaningful remedies remain elusive as various, often competing interests hold their ground and shift blame to others in a scheme that is costing legitimate business hundreds of millions of dollars in higher premiums.

Created by Chief Financial Officer Jeff Atwater, the workgroup began meeting in August to come up with a slate of recommendations to reduce a new type of fraud that involves shell companies, check cashing businesses and “entrepreneurial fraudsters” who use lax regulations to their advantage to peddle workers’ comp insurance coverage that doesn’t really exist to businesses scrambling to compete.

The fake companies buy a cheap workers comp policy for a company that allows them to get a certificate of insurance. The person behind the scam then provide the same certificate to several subcontractors who can present the certificate to general contractors as “proof” they have workers comp. The subcontractors have the general contractors make out checks to the shell companies, which cash them at check cashing stores. Essentially, the shell companies are renting their name and certificate of insurance to uninsured subcontractors.

By having the general contractors make checks out to the shell companies, and using check cashing stores, the fake company can then pay subcontract workers in cash, keeping the whole operation underground, avoiding social security and taxes.

The working group, which presented its findings Wednesday to the House Insurance and Banking Subcommittee, did make a number of recommendations on making it easier for law enforcement to track violators engaged in illegal activity, such as creating a database for all large check cashing transactions.

The workgroup, however, was unable to reach accord on more proactive measures to reduce the frequency of fraud targeting check cashing and other money services businesses.

While records for date still fell, we just missed getting lots more

The heaviest bands of an extraordinarily powerful October snowstorm stopped short of the Capital Region this weekend, but previous record snowfall totals across the Albany area were still shattered by one of the most impressive pre-Halloween blasts of winter weather in the past 100 years.

The storm, which began around 4 p.m. Saturday in Albany after barreling its way up the East Coast, dumped 3.8 inches of snow at Albany International Airport, according to the National Weather Service. That total towers over the previous record for the date of four-tenths of an inch.

Up to 9 inches fell in the highest portions of southern Albany County. Eastern sections of Columbia County saw more than a foot of snow, while 10 inches fell in parts of Rensselaer County. Most of Saratoga County and areas north were dusted with 1 or 2 inches.

The most intense patches of the storm hovered around areas south and east of the Capital Region, with more than 20 inches reported in portions of Dutchess County and more than 2 feet of snow pummeling Berkshire County, Mass., and portions of western Connecticut.

Albany could have easily seen similar totals if the storm’s fragile trajectory had shifted marginally to the west, said Bob Kilpatrick, a meteorologist with the weather service.

“It was a very, very close call,” Kilpatrick said. “If the angle of the storm moved just one degree more toward Albany, we could have seen over a foot of snow in the city.”

As the storm gained strength along the Atlantic and rose toward the Northeast, the concentrated pockets of the heaviest snowfall swayed farther and farther back toward the coast, Kilpatrick said.

Those heavy bands of snow continued to rotate east as the storm approached the Capital Region, settling in a path that narrowly spared the area from a direct hit, Kilpatrick said.

The dense, sticky flakes piled up on leaf-laden trees and power lines around the state, causing over 300,000 to lose power by the time the storm tapered off by 3 a.m. Sunday.

By 2 p.m. Sunday, the number of New Yorkers without power had been cut to 126,000, the Associated Press reported.

National Grid said around 1,700 customers in Albany, Columbia and Rensselaer Counties were still without power as of 5 p.m. Sunday. The storm had caused more than 13,000 people in the Capital Region to lose power.

Central Hudson Gas & Electric spokesman John Maserjian said it may be a week before power is restored to all 129,000 of the utility’s affected customers in the lower Hudson Valley.

Early Sunday, Consolidated Edison reported almost 69,000 customers were without power in Westchester County, as were about 4,700 customers in New York City.

Saturday night, the record snowfall forced motorists to leave their cars at impassable portions of Interstate 84 and the Taconic Parkway. Police said about 50 to 75 vehicles were towed away so the highways could be plowed and cleared of fallen trees. Owners were bused to their vehicles Sunday afternoon after staying overnight in hotels and shelters set up in Dutchess, Ulster and Orange counties.

The storm brought the second-highest snow total on record in October for our area, only beaten by the infamous Oct. 4, 1987 storm in which 6.5 inches of snow fell at Albany International.

In the town of Grafton, 20 miles west of the Massachusetts border, Bill Larson dug his shovel into a thick mound of snow at the edge of his driveway along Route 2. Larson’s snowblower clogged when he tried to push it through the 9-inch-tall pile of wet snow Sunday afternoon.

“I wish I started earlier before the sun started to melt it,” Larson said. “Now it’s just all condensed, thick and really heavy.”

Larson, a 54-year-old postal worker, said he’s used to driving in inclement winter weather, but not this early in the season.

“The worst was on the way home last night after my shift, around 7 p.m.,” Larson said. “The snow coming down so hard and the roads were in real bad shape. People were zigging and zagging and losing control in front me. It was like it was the middle of winter.”

At Frear Park Golf Course in Troy, Jeff Coonan drove down from Wynantskill to squeeze in some early- eason sledding with his three young children: 7-year-old Jack and his 5-year-old twins, Janie and Joseph.

“They started bugging me about once the snow started coming down the other day,” Coonan said, referring to a light snowstorm Thursday that dropped around an inch of snow across the region.

Occasionally shedding their gloves under the bright fall sun, Coonan and his kids coasted down a tall hill on the fairway that approaches the 11th hole, sliding onto the green and nearly into sand traps that border the hole. Rakes used to comb the bunkers still lay in the sand. “Surprisingly, it’s packing nice and we’re getting some pretty good speed,” Coonan said. “We could have gotten more snow, but this is enough for us.”

Temperatures will again reach the low 50s Monday afternoon, Kilpatrick said, eviscerating most, if not all, of the snow in areas that saw under 6 inches just as children start trick-or-treating.

Staff writer Lauren Stanforth and the Associated Press contributed to this story. Reach Fitzgerald at 454-5414 or at bfitzgerald@timesunion.com. On Twitter: @BFitzgeraldTU.

M.R.I. scans almost always turn up something abnormal, but most of those abnormalities are inconsequential and require no medical treatment.