Why Chronic Pain Patients Feel Targeted By Opioid Crackdowns

March 28, 2017 / Thomas Cohn, MD

As opioid overdoses continue to rise in the US, the government, lawmakers and medical personnel are all trying to figure out the best way to reduce these unnecessary deaths. Obviously restricting access to opioids would reduce the number of people who can get their hands on them, and in turn reduce overdose deaths, but it would also unfairly target people who need the pills. People like those suffering from chronic pain. So it’s understandable to see why when lawmakers propose strict rules for who can access these medications that chronic pain sufferers feel like they are being targeted and singled out.

It’s a tough balance to strike, and unfortunately it seems that as a nation we are more focused on what is easy and cheap instead of what will really address the root problem. Putting a band-aid over a large gash might stop some bleeding, but the wound won’t close correctly without stitches. Simply restricting access opioids and painkillers might stop some abusers from getting the pills, but it won’t solve the whole problem. We need to put some stitches in place.

Solving The Opioid Crisis

We’re not going to sit here and pretend we have all the answers for solving the problem of opioid addiction and overdose, but like we said above, simply restricting access is not going to solve the problem, and many innocent people who rely on those medications may no longer be able to access them. Instead, here are some steps that will help address the root problem.

1. Doctor Education – The vast majority of doctors understand that opioids do not address the root problem, but sometimes they are confused by a diagnosis or have seen other treatments fail and they fall back on them. Other doctors cut corners and prescribe pills freely and dangerously. We need to provide better understanding at the top level of how these drugs should be used, how to spot signs of abuse and how to ensure patients are safely taking their medications so that overdoses don’t occur.

2. Systemic Pressure – This problem will be harder to solve, but in many cases doctors are told to see as many patients as possible. If a doctor is feeling overwhelmed or rushed to see a number of patients, they can sometimes fall back on easy solutions like opioids. Doctors need to take their time with each and every patient and ensure they are giving them the best care possible. It’s possible the best care will involve opioids, but it should also involve therapy, exercise and regular abuse checks.

3. Patient Education – Patients also lack understanding of opioids and their abuse potential. Opioids are not a magic pill that will cure your pain, but they can provide temporary relief so other rehab techniques like exercise, swimming or physical therapy are more bearable. Opioids are a passive treatment, and they need to be paired with an active treatment option for best results. Patients also need to learn the warning signs of abuse for themselves and for loved ones who may have access to their pills.

4. Pill Technology – Medical researchers are looking into new abuse-deterrent opioids. They are creating pills that can’t be crushed or that become gooey if a user tries to extract the solution for injection. Other pills come in an extended release form and can’t be manipulated to give an elevated or intense high. More research into abuse deterrent options could prove useful.

Simply saying we need to restrict access to opioids will not solve the problem, and many chronic pain sufferers will be affected instead of those who are actually abusing the pills. That’s why so many patients feel targeted by these proposals. It won’t be easy to reverse this trend, but if we put in the time and money, it can be done.

Opioids – Understanding Dependence Vs. Addiction

December 27, 2016December 28, 2016 / Thomas Cohn, MD

Another misleading article appeared in the paper again last week, this time it is again about the opioid crisis. The headline gets the story wrong, and is truly misleading. It says in the headline “Third of long-term opioid users addicted”. The story is from the Washington Post-Kaiser Family Foundation survey of 622 users of opioids for over two months. In the article it states one third of users are either addicted or dependent on these powerful painkillers. The critical information is in one word that was left out headline and it was the word “or”. Addiction and dependence are two very different things, and two-thirds of the people had neither of the problems. Deaths from opioids are indeed a crisis, as the yearly total of opioid deaths are in the region of 30,000 in the United States – about the same as the number killed by either auto accidents or gun violence.

Chronic Pain

Chronic pain is an extremely difficult medical problem. Pain is caused by hundreds of issues and there is no simple solution to many of the problems related to pain. It is not a glamorous condition, and despite the deaths related to opioids, not much is being done to find better treatments for pain. There has been little government support for finding treatments to pain while billions are being spent to treat addicts. There are no moonshots or big government programs to fund research into better treatments for pain. With a third of the population in the world dealing with pain, it is a wonder why so little is spent on finding solutions.

Addiction Vs. Dependence

To understand the article noted above, knowing addiction and dependence are two different things is incredibly important. Dependence is a condition where the body becomes adapted to a chemical, and if the compound is stopped, then the body goes through withdrawals from that compound. There are a number of compounds like this that are medicines including anxiety drugs and many others. Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. In addiction there is an inability to abstain from behaviors that are detrimental to one’s physical and emotional health.

People who have chronic pain may use opioids to control symptoms and allow for increased daily functions. If they have been on the medications for a long time, then they may or may not be dependent on them physically. If they are suddenly stopped, and you are dependent, the body would go through withdrawals. Understanding pain and dependence is a medical problem and treated best by experts in Physiatry and Pain Medicine.

Addicts use a medicine like opioids for pain relief, but mostly they are used for the pleasure it creates in the brain. They crave the reward it gives and will do whatever it takes to obtain pleasure even if it is causing physical, legal, behavioral, or emotional destruction. Addicts are unable to control their cravings and will continue the activity despite the harm it is causing. The number of pain patients that are truly addicts alone range from estimates at about 5-7% to about 17%. The addicts are usually those who are using pain medicines illegally and are dying. Understanding addicts and treatment is a Psychiatry and Addiction Medicine problem.

Finding a Solution to the Pain

Chronic pain affects a third of the world population. There are not enough good treatments available and the research in this field is poorly funded. Opioids can be a very effective treatment for some people, but they have many drawbacks. Most people can use these medications safely if needed. Addiction is a separate disease, and opioids have now become a tempting drug for many to satisfy their needs. Possibly the best solution to the opioid crisis is finding a solution to pain versus treating another cause of addiction.

Pain Care – When Correlation Doesn’t Equal Causation

October 13, 2016 / Thomas Cohn, MD

It seems that there are new articles being published almost every day on the dangers of opioid pain medications. Unfortunately a lot of the studies are not very enlightening. Worse yet, some are just sensational, dumb correlations without causation.

For instance, saying obesity is correlated to eating is a great example of poor research. If you eat, of course could run the risk of being obese, but if you do not eat you could die, so obviously these findings are not very meaningful.

The latest was an article stating that a third of all adults in the United States in the last year received a prescription of opioid medication, and this is larger than the number of people who smoke cigarettes. The reason this is absolutely meaningless is this number has no real meaning. If you add up all the prescriptions for opioids written in one year and divide by the adult population, this is very likely.

Another interpretation would be that 1 in 3 people had a serious medical issue in the last year and were prescribed pain medication. Most people who have been in the hospital or emergency room for a surgery or injury may get a short-term prescription for pain medications. This is one of the very legitimate uses of these drugs, and should not be demonized. Treating acute pain aggressively at the outset has been shown to reduce the incidence of chronic pain problems. Several days of pain medications after a surgery or serious injury is appropriate but it should not be an ongoing use once the acute episode has healed.

Making Bad Connections

A third of the world population also suffers from chronic pain. A small percentage of those people are helped only by opioid medication and use these appropriately to maintain function and ability. There are many who use these medications extremely sparingly and thus continue to be highly productive in society since then they can control their symptoms. These people are dependent on these medications, they are not addicted, and oftentimes other conservative treatments have failed them. If there were better legal treatments available, many of these people would never use opioids.

Taking a prescription pain medication for a legitimate medical problem is not a significant issue or statistic. Smoking cigarettes for most is a daily addiction, affecting 25 percent of adults. It is voluntary, it causes multiple health problems, and has a huge cost to society. Comparing pain medication use to smoking is a useless correlation with no meaning.

The Complexity of Chronic Pain

March 11, 2016 / Thomas Cohn, MD

Recently the Star Tribune published an opinion piece titled “How not to treat chronic pain” by Ellen Stern. The article was quite interesting, but seems to miss the mark in understanding pain and its management. The author suffers from chronic low back pain. She tried treating it conservatively with the traditional route of management from medications, to therapy, to injections – none were very successful. She eventually underwent lumbar fusion and this also did not relieve her pain. Despite all the treatment she continues to be in significant pain.

The Complexity of Pain

Chronic pain is very complex. All of my patients understand the nature of pain and how difficult it is to find a good management option. Furthermore, since I have chronic low back pain with significant spondylolisthesis and severe stenosis, and have close family with pain problems, I have a very deep understanding of all these issues.

Rule number one in pain management is that there is no magical treatment. Chronic pain is “managed” and not cured. Complaining about the medical community may feel good but does not move you forward. Adjust your attitude, if necessary get professional help, and concentrate on all the things that you can do and not on the negative. If the physicians you are seeing are not helpful, it may be necessary to find someone who works with you better.

Opioid Abuse

The issue with opioids and abuse is nationwide. It is now as much of a problem with accidental deaths as automobiles used to be and is ever increasing. As the country has become more aware of the problem, all prescribers of these medications have become more cautious. There are numerous ways to reduce abuse of opioids, and all patients who receive them are scrutinized. As a prescriber, we are constantly trying to determine if a patient is appropriate for opioids. Since our licenses and livelihoods are on the line when prescribing opioids, most of us are cautious when prescribing. We all can tell stories of success as well as ultimate disasters, so please understand close monitoring of the patient receiving opioids comes with a certain level of danger.

Medical Marijuana

Medical marijuana in general is another complex issue. As with all treatments for chronic pain, it is just another management tool. Like any other compound, it works only for certain people and definitely not for everyone. Further as noted in multiple previous writings, the science behind medical marijuana has been minimally studied. There is very little rigorous research similar to any other drug that has been approved for medical use. Many physicians are reluctant to recommend a compound that has not been adequately analyzed and has solid research behind it. Many compounds in medicine have come on the market and we later find significant serious dangers caused by the compound.

Treating chronic pain is extremely complex. There is no silver bullet of a cure. There is much more that the medical community does not understand about pain than what we really know in detail. The majority of the tools we use today are often quite crude and old. Surgery is often quite brutal, and changes the body often in the wrong way. Morphine and its opioid derivatives are the same concoctions that we used to treat pain over 150 years ago. Research is slowly bringing medicine better understanding of pain. Physicians are struggling with the problems of pain and its treatments and a lack of new and better solutions with good scientific basis. Hopefully more funding and research will lead to better solutions in time since chronic pain does affect over 30% of the population worldwide.

1 in 4 Misuses Chronic Pain Meds

April 15, 2015 / Thomas Cohn, MD

New research published in the journal PAIN suggests that approximately 20 to 30 percent of opioids prescribed for chronic pain are misused. Additionally, the current rate of opioids addiction hovers around 10 percent.

“On average, misuse was documented in approximately one out of four or five patients and addiction in approximately one out of ten or eleven patients,” who were prescribed pain pills as part of their treatment for chronic pain, said Dr. Kevin E. Vowles and colleagues. They added that the new findings provide “updated and expanded” estimates of the opioid problem in America.

Increased Prescriptions, Increased Addictions

To see how increased opioid prescriptions have fueled pain pill addictions, researchers analyzed 38 reports to measure three separate opioid-related problems:

Misuse
Abuse
Addiction

Researchers examined documented cases of dependence, withdrawal and overdose to come to their conclusion. Opioid misuse was classified as “using opioids contrary to instructions, regardless of harmful or adverse effects.” After adjusting for variables, researchers concluded that between 21 and 29 percent of people who are prescribed opioids misuse them.

“If it is accurate that approximately one in four patients on opioids display patterns of opioid misuse, but not addiction, then perhaps more efficient targeting of treatment resources would be of benefit,” said Dr. Vowles.

As for opioid abuse, which is classified as continued opioid use with actual or potential harmful effects, researchers suggested that about 8 to 12 percent of patients abuse their medications.

Dr. Vowles and colleagues concluded by saying that physicians should seriously evaluate if a patient is a good candidate for an opioid prescription, as the dangers seem to be outweighing the benefits.

“We are not certain that the benefits derived from opioids, which are rather unclear…compensate for this additional burden to patients and health-care systems.”

Related source: Medical News Today