Trying to reduce the pain of my patients plays a major role in my day-to-day life as a doctor. When I was in training, there was a big debate going on: Should a doctor prescribe an opioid for non-cancer pain? The answer was Never!
In other words, no matter where a patient’s pain was coming from or how severe, unless he or she was suffering from cancer that had spread, pain management was limited to Tylenol, aspirin (or its NSAID variants), antidepressants (like Elavil), and a discontinued (for fatal side effects) pain med called Darvon.
In the mid-90s, physicians slowly began to recognize that the widespread chronic muscle pain of fibromyalgia actually existed. Unfortunately, rheumatologists were slow on the uptake. Because there were no positive test results with fibro, patients were routinely told they were simply depressed and referred to psychiatrists. After a lot of hesitation, primary care doctors began prescribing small doses of opioids, like Vicodin and Norco, to people with fibro and other chronic pain conditions and the results were astonishing.
The prescribing rule was “start low and go slow” and it still holds true. Patients who are taking high doses of opioids for any chronic pain condition, regardless the cause, always run a greater risk of addiction than those on more modest doses. Fibromyalgia pain can be controlled with small doses and thus addiction is rare. The pain from cancer that has metastasized (spread) requires high doses to quell, but since the disease is most likely fatal, the situation allows the doctor to prescribe higher doses needed to give the patient some comfort as the end nears. Such high doses would likely lead to addiction if used over a long period of time.
Dentists and Vicodin
Dentists have been using opioids for years, prescribing a few days of Vicodin after a dental procedure. As a result, I’ve lost count of the number of patients who have said the following to me: “The only time my fibromyalgia improved was after my dental surgery when I took Vicodin.” Not uncommonly, one of these patients will reach into her purse and extract an ancient bottle containing a half dozen Vicodin tablets, saying “I’m hanging on to these in case I have a really bad day.”
I always ask, “Did you tell your primary care doctor they made you feel better?”
Answer: “Yes. He wouldn’t prescribe more because he said I would become a drug addict.”
Her doctor, many pharmacists, and, unfortunately, lots of politicians are simply wrong on this point. One study after another has shown that about 98% of patients taking correctly prescribed opioids (“start low and go slow”) for chronic pain never become addicted, never get any buzz or high from opioids, never get anything but pain relief. They do, however, still suffer through an occasional encounter with an ignorant physician or pharmacist who, harking back three decades, says something like “This medication is only given to cancer patients.”
The media bray that Americans are prescribed more opioids than anywhere else in the world and that we’ve become a nation of opioid addicts. It’s easy to conclude the two must be related, but they’re not.
It’s true that physicians are prescribing more opioids because they’re now willing to do so for non-cancer pain. If addiction does occur (which happens in roughly 3% to 4% of people), it’s because the doctor is not also prescribing non-medical alternatives for pain control, but rather increasing doses at the patient’s request.
By the way, opioids are the only medications available that are FDA-approved for pain management.
Two issues about opioids need to be aired
The first concerns the phenomenon of withdrawal. Experiencing withdrawal symptoms is not a sign of addiction. Many medications cause unpleasant symptoms if stopped abruptly instead of being slowly tapered. In addition to opioids, withdrawal symptoms routinely occur with antidepressants, anti-anxiety meds, beta blockers, and steroids.
The second concerns psychological dependence. A common example of this is the anxiety patients experience if their pain has been well controlled and suddenly they realize they’re running low on meds and they have no way to get their prescription refilled. They become understandably anxious about their pain returning with a vengeance and possibly experiencing the withdrawal symptoms they’ve read about. This is not addiction. It is a perfectly normal situation called psychological dependence.
I have serious concerns about Washington deciding to criminalize physician prescribers or patients who take opioids to manage their pain. There is no evidence that cutting off supplies of legitimately prescribed, physician-supervised pain meds reduces opioid addiction/opioid deaths, which occur mainly as a result of narcotic street drugs that nobody has prescribed. Here’s a physician who says it well: We need to start putting real numbers and percentages to the problem – not combining all narcotics under the umbrella of the buzz word “opioids.”
Is it Washington’s attempt to distract us from the real issues besetting our country?
Just say no
We must never forget the disastrous backfire the “war on drugs” had during the 1980s, headed by Nancy Reagan and her Just Say No campaign. This paragraph from a story at Think Progress describes the outcome:
Instead of convincing kids not to use drugs, the hysteria around drug use by young people helped create some of the most destructive mechanisms of mass incarceration. Fears of children getting addicted to drugs gave rise to the school-to-prison pipeline. Shortly after the First Lady launched her Just Say No campaign, Congress passed the Drug-Free Schools and Communities Act in 1986, mandating zero tolerance for any drugs or alcohol found on public school grounds. That brought police officers into schools. Those police officers then started arresting students not only for drug possession but also for minor school code infractions, such as throwing Skittles or violating the dress code. Black and Latino kids are far more likely to be arrested at school for these kinds of offenses. Once they enter the juvenile justice system, their ability to graduate from high school, get a job, and stay out of the criminal justice system as adults essentially vanishes.
And now, Attorney General Jeff Sessions apparently intends to re-launch that failed approach. He’s also asking Congress to let him prosecute prescribers and dealers of medical cannabis. By the way, while medical marijuana is not an FDA-approved substance for chronic pain, it is certainly helpful. In my own practice, I find it useful to help chronic-pain patients lower their opioid doses or even get off opioids altogether.
Chronic pain is dangerous to your health
What we’re seeing today is another form of hysteria. Physicians, fearful of being accused of fomenting addiction, are refusing to write prescriptions for pain meds. Over vast areas of the country, pharmacies are refusing to fill pain prescriptions. Patients, under the mistaken fear that their modest Oxycontin prescription will lead to them dying behind a dumpster, are suffering needlessly.
Listen up: untreated, unchecked chronic pain is dangerous to your health. This very important study out of the UK was published just last week. Examining the data on more than 500,000 patients between 40 and 69, those with untreated widespread pain had a significantly higher mortality rate than those with treated pain (and those with no pain issues at all). This higher death rate was not being caused by the condition associated with the pain (e.g., fibromyalgia), but because of the forced inactivity brought about by pain.
The study showed a higher rate of smoking and unhealthful eating among patients in chronic pain, which, added to the inactivity, were responsible for the increased death rates.
So, on the one hand, chronic pain is dangerous to your health and on the other, although you could be helped by using correctly prescribed pain medication, your government says you can’t have it because you might become addicted to it, even though there is no evidence this will ever occur.
Which brings me to a final point
We recently asked Valarie McConville, an occupational therapist, to join us at WholeHealth Chicago. Occupational therapy (OT) is extremely useful in teaching people non-drug strategies for chronic pain. The phrase that best describes the goal of OT is “living life to the fullest.” This may mean a combination of gentle at-home exercises, relaxation techniques, and adjusting the environment both in your home and workplace.
Health insurance generally covers OT, so if you’re a WholeHealth Chicago patient consider scheduling an evaluation. If you’re not a WHC patient, ask your doctor for a prescription that reads “Occupational therapy: evaluation and treatment.”
I don’t know if or when the government will block access to pain medications. I do think it’s worthwhile for everyone in chronic pain to explore non-medication options like OT, traditional Chinese medicine, chiropractic, homeopathy, bodywork therapies such as myofascial release, and energy therapies such as Healing Touch.
David Edelberg, MD