Pain Management And The Opioid Epidemic
Unless you have been under a rock, you know that war has been declared on the use, more specifically, the abuse of opioid medications. You probably are also aware that this nation has a staggering number of citizens living with the burden of chronic pain.
What some have not considered is the impact that this has on honest chronic pain patients. Some of us who are hit hard by changes in prescribing of opioid medications have rare diseases. We are the people who have no medications to treat our diseases, no treatments to alleviate symptoms. We rely on symptom management.
As a patient with Ehler’s Danlos Syndrome, I understand pain. My expectation has never been to be completely pain-free, that is unrealistic. I hope only to have my pain managed to the point that I can live a productive life. I feel like that expectation of pain management is being threatened. Pain is one of the few things that I truly fear.
Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context. The recommendations in the guideline are voluntary, rather than prescriptive standards. They are based on emerging evidence, including observational studies or randomized clinical trials with notable limitations. Clinicians should consider the circumstances and unique needs of each patient when providing care.
Recommendations and Reports / March 18, 2016 / 65(1);1–49
Pill Mills, Dr. Drug Dealer
There is no argument that many individuals are living with, and dying from, opioid addiction. Doctors are running ‘Pill Mills.’ These are drug dealers with medical degrees. One of the most famous Pill Mill cases is that of Dr. Paul Volkman. (This presentation is a fascinating read. If you are a chronic pain patient you will be disgusted by each slide in this presentation.)
The problem with drug dealers like Dr. Volkman, his ‘patients,’ and his associates are the broad-brush strokes their actions paint across the entire pain management practice.
The way that Dr. Volkman dealt drugs has set the standard for the way that even the very best pain management doctors have been forced to practice medicine. His so-called patients have changed the way that the public views true chronic pain patients. This doctor’s negligence resulted in the death of many patients.
Honest chronic pain patients and their doctors always strive to work together to create the most effective pain management program for that individual.
Pharmacists are now practicing medicine in many cases by telling patients that their doses are too high, their prescription is for too much, or making judgments about their customers. Individuals may be turned away by pharmacists. In some states, a pharmacist must act as law enforcement by running background checks before dispensing opioid medications.
Florida pharmacists Bill Napier: “We’re being asked to act as quasi-law enforcement people to ration medications, I have not had training of rationing of medications.”
“…Ora Chaikin has been taking high levels of narcotics for years to control pain associated with bones and ligament destruction due to rheumatoid arthritis and other autoimmune diseases. But Chaikin who lives in Riverdale, New York, says her mail order pharmacy, Caremark, owned by CVS, has been denying her her medications.”
In some cases the pharmacists are being asked to do what they do not want to do, in other cases, pharmacists have far more power than they should. In any case, when a doctor believes that a patient needs a certain amount of narcotic for pain management, the actions of criminals have set the standard of care for the chronically ill and disabled. The requirements set as a result of the opioid crises are having an unintended negative impact on the chronic pain community.
Opioid Use By The Numbers
- The chronic pain epidemic affects nearly 100 million Americans
- According to ASAM, the American Society of Addiction Medicine, there were 20,101 overdose deaths related to prescription pain relievers in 2016
- According to The CDC “From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States.”
- The NIH says less than 4 percent of people who had abused prescription opioids started using heroin within five years
- My favorite: A longitudinal study of drug use, including alcohol and tobacco use, shows month and year use of each drug over time. This shows rise and fall of use over these years. These statistics make it easier to weed out the one-time-only illegal drug users and addiction recovery patients from the overall statistics. These are not commonly removed from cited statistics of opioid abusers.
Good Doctors, Bad Medicine
Good doctors are being asked to do what they know will hurt their patients. When pain patients need pain management that includes adding a narcotic to supplement a well-rounded pain solution but they are pressured to taper their patients off of their narcotic medications, these good doctors suffer alongside their patients.
My own doctor has been lowering my pain medication every month. I have been on a pain contract with my doctor for six years. I submit to regular drug tests to prove that I am not taking extra narcotics and to prove that I am taking my doses and not selling my narcotics. In spite of my compliance, I am required to return to a time when the pain was close to the forefront of my mind.
Pain leads to fear, anxiety and other mental health issues. These are some of the unintended negative consequences that people like me will live with as our pain increases. Pain also leads to a decrease in productivity, exercise, and social life. These are all things that I have fought hard to gain back as my pain management has improved. Now I am, simply, afraid. That is what this is mostly about, fear.
I have a good doctor. He is actually a great doctor. My doctor does not rely only on narcotic medications. I take nerve medications and I receive epidurals for my myriad spine conditions. I have been prescribed physical therapy, I have braces and a TENS unit. Still, in spite of all of the other modes of pain relief, the narcotic portion of my pain management is an important part of the multimodal approach.
I have another issue. Using a transdermal medication like both my pain medication and my estrogen is helpful because I suffer from malabsorption. The medications I take orally do not fully absorb into my bloodstream and my doses must be adjusted to compensate for this issue. Patch medication solves this problem.
What Will I Do?
Acupuncture will become a bigger part of my life as my medication decreases. As my fentanyl has decreased I have been allowed to supplement with another medication. What will I do? I am not sure, and frankly, I am afraid of what will happen in the months to come. How many epidurals can I tolerate before my organs are damaged? How much daily functionality will I lose?
The CDC and law enforcement may make doctors feel as though they have little to no choice when it comes to prescribing, but they do. My prescription history in the state database is unremarkable, and my treatment history is documented as stable, and multimodal it is clear that I am not a med-seeker. I am happy to do all that I can to find the best ways to have less pain. If I can do that without opioids then I will do so happily. No one WANTS to be on opioids if we don’t have to be. I am not sure if those who do not suffer from chronic pain are aware of this, but we do not get high from our pain meds, we get some relief from pain.
So, I can only repeat that my goal is a simple one, and I do not think it is out of line: I do not expect to be completely pain-free, I just want to live a functional and productive life.
Do you have a pain management story? Let me know!