This week there was another article on the pain management problems at the Veteran’s Association. As with all practices, the VA has had a long history of pushing opioids/narcotics as a main treatment strategy. Then suddenly a year ago, the VA decided these were not great management options and everyone had to be weaned to low dose or off these medications.
Options of management were not really given to anyone; it was just going to be the policy. This week, it was announced that one of their lead physicians has been awarded a grant to study options in weaning. Two options seem to be available, either with help of physical therapy and psychology, or possibly a slow wean by the pharmacist or with your physician.
Weaning Off Opioids
Pain is extremely complex. When a cause of the pain can be identified and treated, it is the best of all cases. Unfortunately, about a third of the population in general does suffer from chronic pain, and in many cases there is no reversible cause. Options to manage pain then become the course. Sometimes it is simple to manage and very successful. However there are oftentimes multiple generators of pain signals and it becomes difficult to develop a successful management routine. Treating pain does take a degree of compassion and it also often requires multiple strategies. Just saying no to drugs, especially to opioids, is a bit short sighted.
Addiction and abuse of opioid medications is extremely well documented. Overdose deaths are becoming rampant. Those who have pain are not resistant to having problems with opioid addiction. Furthermore, combining some medications, like those for anxiety or sleep with opioids significantly increases the risk of overdoses. Patients who have had problems with addiction to drugs, smoking or alcohol also have higher risks for addiction.
There are many ways to treat painful conditions. One of the most important aspects of treatment of pain is working with a skilled, experienced, board certified expert in pain management. These are medical experts who hopefully have extensive ability to identify the causes of pain and develop multiple treatments to help manage the combination of problems causing the pain. They can help coordinate a variety of disciplines covering psychological needs, physical therapy, interventions and all the way through a variety of medications. As noted, there is not a single magic cure, especially not medication alone.
Unfortunately, the VA has seen a problem with opioid abuse and decided that this should be the focus of pain management. The goal appears to be to kill the devil, and get rid of this class of medications for most patients. Pain is much more complex than treatment with a single medication. Some people are dependent upon this as part of their overall management. At this time, there are not a lot of effective medications to treat pain. Research is making strides at better understanding the mechanisms involved in pain and the cells in the body that perpetuate the problems. Still we are definitely lacking solutions.
Instead of making opioids the enemy, maybe there is a better strategy. At this time we need to work on better treatments for pain instead of just eliminating medication options. Using pain management experts who can employ multiple strategies to properly diagnose and treat pain problems is what is needed. The recognition is needed that decisions on treatment options of pain should be made by pain experts, not by addiction experts administering a budget policy. Pain is truly complex and not simple to fully diagnose, manage, or treat.
Thomas Cohn, MD
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