Thursday, Jul. 12th 2018

Opioids Addiction and Chronic Pain

Nearly every day there is another story in the news about the tragedy of addiction in America. Much of the focus on this deadly disease is on opioids. Addiction and overdose results in tens of thousands of deaths annually in the United States. Many of these addicts aren’t just taking opioids. They often overdose on combinations of drugs. The medical term for ingesting multiple medications is, polyphamacy and it’s found in the majority of overdose deaths. Anxiety drugs from the Valium, Xanax family, benzodiazepines, are particularly dangerous. Opioid overdose results in respiratory depression, dangerous slowing or stopping of the breathing reflex, so taking too much, especially with other sedatives is a death sentence. America’s problem with addiction, focuses on opioids, the leading actor in this complex tragedy. Addiction is not new to mankind but our substances today, like all aspects of our hectic lives, are on overdrive. Prescription opioids have given way to heroin and criminally produced synthetics like fentanyl derivatives which now are the leading opioid killers. The opioid story is not a simple one. These potentially dangerous drugs are also important in the treatment of one of the most important medical disorders in America. Chronic Pain.

It is rare to hear anything about chronic pain in the opioid debate. Chronic pain has many causes . Accidents, surgeries, congenital disorders, degenerative spine and joint disease, headaches. Doctors recognize the impact of daily pain and see patients with it every day. The scope of chronic pain is staggering. Pain contributes to stress and other diseases including cardiovascular disease and mental illness.

Chronic pain is responsible for trillions of dollars in lost wages, medical treatments, and disability payments. While the financial impact of chronic pain is staggering, it is the suffering and misery that it brings to individuals and families that is most significant. Nearly one out of every three Americans suffer from some form of chronic pain. If you don’t have it, you know someone who does. Not everyone is miserable, but millions struggle. Chronic pain can’t be cured or fixed. It’s sufferers have more depression and other mental illness. It ruins marriages, destroys families, breaks up friendships and keeps people from being productive at work and at home. Unmanageable pain can lead to suicide. Pain is a physical problem, but it is far more than that. It is a truly biopsychosocial, spiritual problem. It robs the sufferer of the joys of life. Pain steals by preventing us from doing. It’s not just that we hurt, its biggest challenge is how it prevents us from doing what we want and need to do.

There’s more bad news.

Though we have come a long way in finding useful treatments to help manage it, we are lousy at treating chronic pain. It is often very difficult to diagnose precisely and it is usually not associated with the words “cured”, “fixed” or “healed.” Pain specialists use the word “manage”, a term that many patients will never accept or agree with. Living with chronic pain is often a life-long chore, and like other chronic illnesses it needs ongoing management. Finding someone to help with this incurable disorder isn’t all that easy. Treatments for chronic pain are best broadly focused or “multidisciplinary”, a loaded medical word that means you have to Do lots of things to get it controlled. Most important are self motivated activities, such as exercise and finding ways to keep moving, avoid painful triggers, and get engaged in diversionary activities to get your mind right. There are also passive treatments available like massage, acupuncture, injections, nerve stimulators and implantable devices, manipulations and other therapies that help some but don’t cure. Having a compassionate support system is critical. If you like clean problems with fixed answers, don’t pursue a career in chronic pain management. One other thing, chronic pain also can’t be cured or fixed with pills.

So back to opioids. How did they become public villain #1? The 30-40 year history of the rise of opioids in medicine is a long fascinating story. Though opioids have been around since antiquity and used by doctors to treat pain for centuries, chronic pain wasn’t widely treated with opioids until about 1995. New drugs like OxyContin and patch fentanyl were released around the same time that respected physicians began talking about benefits of using opioids over a long term to treat pain. Doctors and pharmaceutical companies clearly got the early stages of this opioid rollout very wrong as we began to use them for chronic pain suffers in the mid 1990s. We were lead to believe that high opioid dosing didn’t matter. Big pharma made sure there was a lot of drug out there for good but there was not enough attention to the potential for bad. They pushed pushed their products with vigor and carelessly. Bad science was touted as good and Doctors were fooled. Pharmacies were later sued and paid large settlements. We asked patients to score their pain with a 0-10 pain score, which is the worst monitoring tool for chronic pain ever devised, yet we continue to use it to adjust medication. You can’t try to lower chronic pain with a simple number system. The use of the 0-10 pain score in my opinion. Has done far more harm than good and has helped create the problem of overprescribing to chronic pain patients .

With the prescribing problems however, we also learned something else very important. They worked. Many many of our patients were much better on reasonable doses of opioids. For this large group of patients, the medications were doing exactly what we had hoped. They lowered pain intensity, and made people feel better. For this group with successful management, they didn’t cause excessive side effects, didn’t create a tolerance to the pain relieving effects as they relieved pain and suffering. These patients also didn’t behave like addicts. Yes, they needed the medication, but not like an addict did. They needed it like patients with high blood pressure. If they didn’t take it, their disease got worse again, i.e. the pain intensity came back. In that sense we used the term dependent, not addicted. The relief and improvement was dependent on the daily use of the drug. Patients got some of their lives back. They also improved psychologically.

Most good doctors recognized early on that, like other drugs there was a big risk/benefit in prescribing opioids. This isn’t unusual. Doctors deal with this with nearly every medicine.
Few people are aware that there may be 16,000 deaths annually from the use of Non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen, drugs purchased over the counter. The risk from these drugs is even higher in the elderly who are at risk from GI, renal and cardiac complications. NSAIDS and other drugs however, kill slowly.

Opioids in the hands of an addict kill more dramatically and suddenly. Young people are also more prone to addiction, lives ruined and destroyed early, suddenly, make an impact. Addicts ramp up the problem by doing what addicts do, lying , stealing, selling medicines and doing whatever it takes to get more drug. Overdose is front page news and dirty work in the ERs and on the street.

Still, in the midst of all of the bad, there were patients being helped, lots of them. Elderly patients who stopped crying all day, fathers who went back to work. Depressed patients that suddenly had some hope that their lives would’t be lived in persistent pain found their depression lifted. These examples were far more prevalent than many people realize. It proved to Doctors that opioids had a place in the management of chronic pain. The question was how to mitigate risk. How could we continue to use opioids smarter to decrease the risk of addiction and the horror of overdose.

We still have a lot to learn but we are getting smarter. Practices have been changing broadly. We are following guidelines that make prescribing more uniform. We are closely screening, monitoring and educating our patients. We Are limiting doses to levels that appear to be safer. We are working with pharmacies and insurance companies to keep a watchful eye on prescriptions.

Sadly though we are also seeing many physicians completely abandon opioids altogether, some even claiming that it’s not their job to treat pain, a problem one out of every three of their patients suffer. The fear of doing it wrong and being blamed is understandable. A knock on the door from the DEA scares doctors a lot. There have been doctors who essentially sell prescriptions with clear knowledge that they were serving addicts not treating pain patients. The appropriate focus is on those drug dealing physicians, not on legitimate prescribing with intent to help manage chronic pain. Doctors need support to make sure that their intent and practice allows them comfort in doing the right thing. We need to provide better support and treatment for those who develop addictions to opioids yet we also can’t pull these vital medications away from patients whose lives have been dramatically improved by their use.

The answer to the opioid crisis is challenging. Opioids remain one of the most valuable tools we have in the management of chronic pain. We must pledge to carefully use them, to continue to study and learn more about them and apply the knowledge and experience to our practice. Our suffering pain patients deserve nothing less.

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