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.
Be well,
David Edelberg, MD
Hi Andrea
All the quotes show is that not all doctors are in agreement. The addiction rate among chronic pain patients managed by a physician who knows how to prescribe them is actually very low.
Dr E
Help, Dr. E, I’m in an argument with a friend about this issue. Below is a bit of what he wrote. How would you respond?
The 2016 Guidelines issued by the CDC
I doubt that making these Guidelines mandatory would be very destructive (although how much it would help without more government control over distribution of opioids is unclear).
A few choice quotes:
“Beginning in the 1990s, efforts to improve treatment of pain failed to adequately take into account opioids’ addictiveness, low therapeutic ratio, and lack of documented effectiveness in the treatment of chronic pain. Increased prescribing was also fueled by aggressive and sometimes misleading marketing of long-acting opioids to physicians.1 It has become increasingly clear that opioids carry substantial risks and uncertain benefits, especially as compared with other treatments for chronic pain.”
“The science of opioids for chronic pain is clear: for the vast majority of patients, the known, serious, and too-often-fatal risks far outweigh the unproven and transient benefits.”
Andrea Holliday
Ahhh.. it does often come down to the financials, doesn’t it? I appreciate your grounding in the challenges we face around insurance coverage for non-pharmacologic care. And, I will continue to do what I can to make Massage, Craniosacral Therapy, Reiki, Lymphatic Drainage and other bodywork modalities accessible.
If you have any suggestions on what we, as health care practitioners, can do to influence the landscape, please do share!
Ellen Winick
Hi Ellen
Long answer: Your question is complicated but basically the issue is one of economics. “Hospitals must provide” then asks “who’s going to pay?” People are generally only in hospitals a few days and if they need pain management it’s only for post-operative pain. Nothing really works for this except opioids but you’re not on them for long term use.
Long term pain management is almost always an outpatient issue. Your insurance will cover chiropractic, physical therapy and sometimes acupuncture. Other non medical therapies like hypnosis, biofeedback, massage are usually not covered. With insurance companies barely making ends meet, if asked if they’d start covering this, they’d answer (as one Humana executive said during a seminar on alternative medicine “Why should we pay for something that people are willing to pay for themselves”)
Let’s rephrase this: an acupuncture treatment costs about $75. One hundred twenty (120), about a one month supply, oxycodone costs aboout $25 at CVS
Short answer: don;t hold your breath
Dr E
Dr. E,
I am a 64yr old woman who has had chronic pain since 2008. I kept refusing pain meds from my Doctor because I was afraid of addiction. He kept saying the same things in your article. Finally in 2014 or 15 I took a good hard look at what my life had become, and it wasn’t pretty. Constant pain affect every aspect of your life. I was depressed, not sleeping(nights are the worse)and had self isolated. I finally chose pain meds. I only take them at night. I can manage durning the day. But at night it is a whole different story. I go thru a routine I developed and then if the pain continues, then I take two oxycodone 5 mg immediate release. The interesting thing as the pain continues my anxiety level goes way up. I almost reaches panic stage.
My Doctor retired and his replacement thinks I take too much. It is a constance worry that one day I am going to see her for a refill and I will be told no. She arbitrarily reduce my dose to one or less a night. It took 3 months for me to get her to let me go back to two a night.
Anyway…I just wanted to thank you for your article. It will be posted on my FB page and I will show it to my Doctor
Thank you.
Bridgette A. O’Malley
Bridgette O'Malley
Thank you so much for this article, Dr. E!! I will def be sharing this with my family that is involved with my daily life so they know that these aren’t only my opinions and thoughts, that there are doctors that think and say the same things.
I have seen so many doctors that tell me all I can do is take NSAIDS (even tho my stomach is so sensitive so they cause really bad and dangerous side effects) and to learn to deal with the pain because they are worried about the repercussions. Im glad that you see the bigger picture, you understand, you are compassionate and that you are the same person online in your articles as you are in the office. There are so many doctors that say one thing in their profiles or online writings and act the complete opposite in the office. I’m so happy I found you as my doctor and that I found your clinic! I have been wanting to try alternative therapies but I either get told by doctors that they won’t benefit me or I would have to go to several different offices to get separate treatments which would turn my health care into a full time job. I was about to give up on my health issues until I saw you! At the risk of sounding like a groupie you are a great example of what these new doctors just out of med school should strive to be.
I have read one study(Im almost positive it was on the CDC website) that methadone makes up over half of the overdose deaths. I agree that it shouldn’t be grouped under the umbrella term opiates, that there should be separate numbers and statistics for each opiate commonly prescribed for pain. Maybe then there wouldn’t be mass fear of opiates because of this “opiate epidemic”
Patricia, you are correct, if dental costs were more affordable then health care costs would drop as well. Having bad teeth can lead to so many problems-heart attacks and strokes are two of them. My oral surgeon won’t do any work until I was stable in pain management. He said as a chronic pain patient my dental problems and my post procedure pain are and would be much more painful than a regular person. I have to pick and choose what can be done because I am only allowed so much a year to spend on dental work and I need such extensive work done I have to choose between buying a home or fixing my teeth. So if it were more affordable I could get it done all at the same time and alternative therapies might be enough to control my pain from my other problems.
Laura Conrad
Dear Dr. Edelburg,
I was diagnosed with fibromyalgia in 2001. I have read, researched and been to over 20 different doctors since my diagnosis. I have tried an endless number of medications, diets, supplements ect. but continued to suffer.
For the past three years I have been on doctor monitored opioid treatment. During this time I have never once needed to increase my dose and it has worked wonders.
Recently, due to unending pressure from family who read media reports about “The opiate crises” I stopped my medication. The result was horrific. I spent three months in bed in pain. I couldn’t lift my arm to brush my hair and struggled to walk to the bathroom. I just lay in bed and hurt, and eventually didn’t want to live any longer. I don’t think I was suicidal, I just didn’t have ANY quality of life and couldn’t imagine spending the next 40 years or even another day that way.
Thankfully, I went back on my regular dose of pain medication prescribed by my pain specialist and I am now able to function relatively well. I can shower and cook meals and even do light housework. The only positive part of the experience is how grateful I feel to have a medicine that helps and I am reminded of how precious our health is.
Anyone who reads this please understand that opioid treatment is a matter of life and death for me. I do not abuse the medication and I do not “get high” it lessens my suffering. I more than anyone would love to never take a pill again but I am grateful for the relief from a very complicated disease.
Thank you Dr. Edelburg for your intelligent and fact based response to this situation regarding the myths of addiction. I have spoken to many doctors while seeking treatment and you are one of the very few who truly understands this extremely debilitating disease. THANK YOU!!
Dr. Edelburg you
Jennifer Arnold
Dr. Edelberg,
Thank you for this article. I fully appreciate and agree with your perspective. I am wondering if you think the new Joint Commission requirements related to Pain Assessment & Management will result in positive uses of Alternative Therapy for pain management? The standards indicate that hospitals must provide “nonpharmacologic pain treatment modalities”. What’s your thought on how this might play out? -Ellen Winick, Wellness Practitioner & Educator
Ellen Winick
Hi
That number is definitely too high. He should have received about 3 or 4 days of oxycodone at the most, with instructions on tapering his dose and then consider alternative pain management techniques. This large # of pills for an acute condition is one of the first government restrictions you’ll be reading about. In a newly reported study, most patients prescribed postoperative opioids never even use them.
Dr E
The son of a friend had foot surgery to remove a large bunion. The son, a man actually, 48 years of age, was prescribed oxycodone for the pain. He was given 60 in number. This number seems excessive for bunion removal. Wondering if this prescription for 60 is standard.
Kathryn Morse
Most physicians don’t understand how to prescribe pain medication, especially the correct use of extended release forms which have the benefit of avoiding peaks and valleys and eliminating or reducing some of the undesirable side effects such as an initial “rush” or “high”, nausea, and sedation.
I needed a hip replacement but couldn’t afford dental work that needed to be completed first. I was able to remain functional for three years taking ER Tramadol while I saved for the dental work; when I finally had the hip replacement I simply stopped taking the ER Tramadol and took maybe half a regular tab once or twice a day for a couple of days.
The side effects of properly used opioids are much less scary than the potential damage which can be caused by steroids and nsaids.
PS – a lot of health problems and health care costs could be reduced if dental care were affordable. It took three years to save for the cost of extractions and full dentures – even with”insurance” – and I only went that route because the cost for “restorative” dental work was similar to a luxury car or small house.
Patricia Woodbury
Thanks for this, Dr. E! You prescribed me low-dose Oxycontin for my fibro a few years ago, and even I thought the panicking at unfilled prescriptions and the physical withdrawal symptoms from going without surely had to be signs of addiction! After about three rounds of those experiences, I stopped taking them because it didn’t seem worth it — but that was also because they weren’t really helping my pain anyway (story of my life). But for people who are helped by them, this is so important to know!
Angie