The Opioid Epidemic: Where Do We Go From Here?

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In my last post, The Opioid Epidemic: How Did We Get Here?, I outlined the many factors that contributed to the current state of affairs in this country in regards to opioid use. But now that we’ve established we’ve got a problem on our hands, what exactly do we do about it?

We need to stop placing blame. This is the least constructive thing I’ve witnessed so far when it comes to addressing the current crisis. It is not one person’s fault. Heck, it’s not even one group’s fault. The second we start acting like it is, we lose all sense of personal responsibility. And it’s hard to right what’s wrong if no one will take ownership. So, for the sake of this exercise, let’s just assume it’s everyone’s fault and get on with it.

We need to remember that we’re on the same team. Lately, it seems like the healthcare setting might as well be a season of Survivor. Doctors vs Patients: Who Will Prevail? Doctors feel rushed, taken for granted, and sometimes taken advantage of. And patients feel like they’re not being heard and their needs aren’t being addressed. But it’s important to remember that we both want the same things when it comes to chronic pain: to reduce pain and to increase function. Patients with pain want to feel better and doctors want to help them feel better. Honestly. But we may have different ideas about how to achieve that, so it’s more important now than ever that we are open about our concerns, our expectations, and the plan going forward. (If X doesn’t work, then we’ll try Y.)

pills-1021444__180If doctors are resistant to prescribing pain medications, it’s not because we want to maintain some sort of control or power over the situation. It’s the easiest thing in the world to write a prescription, and to feel like a hero for it, but that’s not doctoring. Doctoring is talking to your patient, listening to their complaints, and deciding on a treatment plan that has the best chance of helping them without harming them. When we are faced with data that shows no long-term benefit to opioid medications, and then we see the potential harm they can cause, we do not take the decision to prescribe these medications lightly. That is not to say that I will never, ever prescribe opioids ever again. But each and every time I do, I think long and hard about it. And I hope my patients can appreciate that about me, because it’s unlikely to change.

We need to understand the purpose of pain. Pain results when a neurologic signal is sent from a certain body area to the brain to alert us that something is wrong. It lets us know to jerk our hand away from a hot stove or to seek medical attention after an injury. In a perfect world, anything that generated pain would be fixable. Unfortunately, that is often not the case. Patients sometimes have pain from an identifiable problem that can’t be fixed. Patients may also have pain whose origin cannot be detected using our current diagnostic tools. In those cases, it is important to understand that we can rule out the potentially life-threatening causes of pain by taking a good history, doing a good physical exam, and ordering the appropriate blood work and imaging studies based on our patient’s complaints. After that, we are often left with pain and other symptoms that can be managed, but not fixed.

Once we have established we are dealing with a condition that causes pain but does not have other damaging effects on the body, our goal is then to reduce the pain—or, more pain-1015579_960_720accurately, reduce the perception of pain. Pain causes an increase in certain neurotransmitters in the brain. Just like depression, managing it is often an issue of modulating the neurotransmitters to alter the experience of pain. Actually, a few antidepressants have been found to be effective in the management of certain chronic pain conditions for this very reason.

A long time ago, someone asked me a question I didn’t have a great answer for: If a tree falls in the forest and no one is around to hear it, does it make a sound? In that same vein, I ask you: If a pain signal is generated but the brain doesn’t perceive it, does the pain really exist? I would argue that there is one answer to satisfy both of these brain teasers: It doesn’t really matter! It shouldn’t matter if I’m taking an antidepressant instead of a narcotic. If I don’t feel pain (or even if I feel less pain) and there’s nothing life-threatening going on in my body, I’m happy. End of story.

We need to be open to other options. Contrary to popular belief, opioids are not the be-all and end-all for pain unless they’re being used strictly for palliation (i.e. focusing on pain management without concern for regaining function, usually for patients that are nearing the end-of-life). It’s easy on a physician’s part to write the prescription, and it’s easy on the patient’s part to take it, but opioids don’t do anything about the underlying reason for a patient’s pain. They don’t improve patients’ ability to function, and they can actually lead to an increased sensitivity to pain. As I like to tell my patients, opioids are a sledgehammer when what you need is a chisel: they’ll get the job done, but it ain’t gonna be pretty.

massage-1015570_960_720Happily, there are many other options available to us for the treatment of pain. There are non-pharmacologic treatments such as physical therapy, yoga, massage therapy, meditation, and multiple other modalities. On the medication front, we have anti-inflammatory medications, anticonvulsants, antidepressants, muscle relaxers, topical medications, and anti-anxiety medications. There is also the option of regional analgesia, which includes a variety of procedures that can be performed to focus in on a specific painful area. Depending on the type of pain a patient is having, one or more of the above options is likely to be more beneficial than opioids and will almost certainly result in improved function and lifestyle.

A major hurdle we face is that some (not all) of these treatments take time to be effective. The obvious benefit of opioid medications (i.e. I take my pill and I feel better in about thirty minutes) is hard to overlook in favor of a treatment that may take weeks to become effective. However, they have the potential of benefitting our patients long-term, as opposed to opioids, which have not been shown to be beneficial in the treatment of chronic pain. But if we can convince patients to invest in themselves, in their long-term well-being rather than a short-term improvement in symptoms, then we may help them avoid a lifetime of opioid dependence, depression, and chronic misery.

We need to stop viewing ourselves as the outliers. The sooner we accept that we are all subject to the same rules, the better off we’ll be. If we don’t, we stand to lose even more autonomy when it comes to pain management. I’m speaking to physicians and patients, here. Most of us wear a seatbelt when we drive, even though we don’t expect to get in a car accident. We do it because 1) it has the potential to be helpful and 2) there could be consequences if we don’t. It is not advisable to throw caution to the wind, say “it’s not going to be me today,” and leave the seatbelt in its casing. Seatbelts work because the majority of people use them the majority of the time. Once people start feeling like the rules don’t apply to them, the system breaks down. What you really don’t want is for doctors to be deciding who looks like they could be a drug addict, and treating those people differently than their other patients. No, we need a standardized system and we need physicians and patients to agree to play by the rules.

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The fact remains, the United States comprises 4.4% of the world’s population, but consumes 80% of the world’s opioids. The problem in this country is not pain. Other populations struggle with chronic pain, they undergo surgeries, and they suffer from terminal illnesses just like we do. The problem is much deeper. It’s cultural, it’s engrained, and it’s not going to be fixed overnight. We are all part of the American culture, even if we’ve never taken a pain pill, and we cannot be isolated from our environment as different from everyone else.

Recent surveys have suggested anywhere from 11-15% of the United States population suffers from chronic pain, defined as pain lasting at least 3 months. That’s about 45 million people. Let’s say for the sake or argument that doctors only prescribe opioids for about 10% of those people, and only 1% of those develop an addiction or experience a fatal overdose. Those numbers seem pretty small, right? That’s 45,000 people whose lives have been ruined by injudicious use of opioid pain medication. It’s easy to say “it won’t be me,” but as physicians we have to remember that it will be someone. We treat enough people that the numbers say we will likely pills-824994__180harm someone by prescribing opioids. That is why we can seem so unnecessarily cautious. That is why we weigh the options so carefully. That is why we have pain contracts and rules. If your doctor is cautious about prescribing opioids, it usually means they care.

We need to accept that the problem won’t be fixed overnight. It took twenty-plus years to get to this point, and there is no quick fix. It will be tedious, painful, and slow. But if we—doctors and our patients—don’t use this opportunity to shift the pendulum, it will be shifted for us in a much less desirable way.

There will be hoops, so many hoops, to jump through in order to prescribe opioids when we think they are necessary. Someone outside of the medical profession may have to approve each prescription—much like the prior authorization that is necessary for certain medications and diagnostic studies now. There may be regulations about how many of these medications drug companies can produce, therefore driving up the cost for patients.

I really don’t want it to get to that. I don’t think anyone does.

https://www.acponline.org/system/files/documents/about_acp/chapters/mn/12mtg/belgrade.pdf

https://www.asipp.org/documents/ASIPPFactSheet101111.pdf

http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

http://www.addictions.com/opiate/10-opiate-addiction-statistics/

http://recoverybrands.com/drugs-in-america-vs-europe/

 

 

 

 

 

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The Opioid Epidemic: How Did We Get Here?

Welp, we’ve done it, folks. It’s finally come to this. There have been so many deaths from opioid overdose, so many addicts created, so many pills diverted, that the CDC is getting involved. Opioid pain medications, commonly prescribed to treat acute and chronic sources of pain, are a significant cause of morbidity (harm) and mortality (death) in America. In 2014, the CDC reported a total of 47,055 drug overdose deaths in the United States, 61% of which were attributable to opioids.

So how exactly did we get here? Like most things in medicine, there is not one simple answer. But it’s not that hard to trace things back a few decades and pinpoint some major influences.

pain-1015579_960_720Pain as the fifth vital sign. In an effort to standardize and improve pain treatment for patients, a national initiative called Pain as the 5th Vital Sign (P5VS) was rolled out in the late nineties. The well-meaning folks who began this initiative were trying to improve the health and well-being of the over 34 million patients in this country that suffer from chronic pain. Unfortunately, a study published in the Journal of General Internal Medicine in 2006 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/) showed no improvement in pain control after this initiative. However, this practice still persists throughout medicine, despite there being little evidence to support it.

One problem with assessing pain as a vital sign is, unlike blood pressure and oxygen saturation, it’s completely, 100% subjective. I can’t count the number of times I’ve had a patient tell me their pain – on a scale of 1 to 10 – is an “eleven” or even “ a hundred.” How do I, as a physician, interpret that? It’s impossible. Objective signs of pain – elevated heart rate, elevated blood pressure, inability to speak comfortably, and certain exam findings – don’t correlate reliably with patients’ self-reported pain scales. I’ve had patients writhing in obvious, excruciating pain who would rate their pain as a seven, and I’ve had patients casually texting on their smartphone who tell me they have 15/10 pain. Both of these people deserve to have their pain treated, but it often involves a little trial and error to get it just right.

Another issue with the initiative is that the goal is for pain to be a zero out of ten. Often, especially in the case of chronic pain, that shouldn’t be the goal. The goal should be getting a patient to the point that they can be functional, so they can reasonably do the things they need to do to be a productive member of their family, their community, and society as a whole. Unfortunately for those with chronic pain, the concept of being pain-free may be unrealistic. If you must be completely sedated before you experience zero out of ten pain, then we’ve missed the mark. We haven’t improved your life, we’ve erased it. There needs to be a happy medium.

OxyContin. The time-release version of oxycodone, OxyContin, was brought to market in medicine-385947__1801996. It was heavily marketed, both to consumers directly and to doctors. It was supposed to be the best thing to happen to chronic pain in the history of chronic pain (i.e. civilization). We were told the chances of addition were miniscule because of the time-release formulation, and the potential benefits were unimaginable. The pharmaceutical company that made OxyContin (getting a new patent for a drug that had been around for the better part of a century) did a phenomenal job of getting their product out there, and doctors who hesitated to prescribe it were vilified. It was a veritable love fest, reminiscent of an Oprah Winfrey episode. “You get OxyContin! You get OxyContin! Everyone gets OxyContin!”

If you’re reading this, you probably know (or at least have a hunch) that things played out a little differently. Oxycontin became one of the most abused prescription drugs to date and is estimated to cause 100,000 drug-related deaths worldwide per year.

Of course, OxyContin isn’t the only prescription drug out there making its way through our communities. It seems there are too many to count these days. And at $10 to $40 per pill, they are worth more than their weight in gold. It’s not uncommon for people who become dependent on prescription pain pills to end up turning to heroin because it’s cheaper and easier to get than a Percocet.

Patient Satisfaction: Patient satisfaction is not, in and of itself, a problem. It’s not that we don’t want our patients to be happy. It’s quite the opposite. But since we’re dealing with health issues and not an ice-cream sundae, sometimes it’s just not in the cards. For cigarettes-83571__180example, sometimes we must tell a patient that their weight is negatively affecting their health. Or their smoking. Or any other number of bad habits. It’s the right thing to do. If we didn’t do it, we would be doing our patients a disservice. But it’s still not always nice for patients to hear. It doesn’t necessarily give them a warm, fuzzy feeling when leaving our office, nor does it make them want to send their friends and family to us to receive the same kind of tough love.

In a much talked about study published in the Archives of Internal Medicine in March 2012, Dr. Joshua J. Fenton and colleagues reported that the most satisfied patients had an increased hospital readmission rate, had the highest healthcare expenditures, and had a 26% higher mortality rate than their less satisfied counterparts.

It is not always satisfying to be seen by a doctor, told that you don’t need a test or prescription, and be sent on your way. But sometimes that’s the best care. Sometimes it’s a viral infection, and antibiotics are more likely to hurt you than help you, so we don’t prescribe them. Patients often don’t feel as if they’ve gotten their money’s worth when that happens, but it is important to remember that your doctor has had a minimum of seven years of training to be able to provide their expert opinion, and that it is much, much harder to provide reassurance than it is to write a prescription or order a CT scan.

In the case of opioid pain medication, not only is it often not medically indicated to use pills-824994__180these medications, but we also take a significant risk each time we prescribe them. We risk our patient developing a dependence or addiction, we risk the medications being diverted or abused, we risk saddling patients with side effects that can be worse than their primary complaint (such as severe constipation and even narcotic bowel syndrome), and we risk someone dying from an overdose of medications we prescribed. Not only are we then “doing harm,” which we took an oath against, but we could even possibly be implicated in someone’s death. I’m sure no one’s forgotten Conrad Murray, the personal physician of Michael Jackson, who was convicted of involuntary manslaughter after Jackson’s death. That’s an extreme case, sure, but it can happen.

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So, what can we do now that we’ve gotten ourselves into this mess? Stay tuned for my next blog post, The Opioid Epidemic: Where Do We Go From Here?

Originally published on Huffington Post May 8, 2016: http://www.huffingtonpost.com/kristine-scruggs-md/the-opioid-epidemic-how-d_b_9865680.html?utm_hp_ref=impact&ir=Impact

CDC: http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

Oxycontin: http://motherboard.vice.com/read/how-big-pharma-hooked-america-on-legal-heroin

Pain as 5th Vital Sign: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/

CDC Morbidity and Mortality: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm

Patient Satisfaction associated with higher readmission and death rates: Fenton, Joshua J., MD, MPH, et al. Archives of Internal Medicine. March 2012.