Someone has to make sense of this whole big mess we’re in. It all swirls around the issues of pain treatment and substance use disorders. We constantly hear about the opioid epidemic, overdose deaths, whether intentional or accidental. We hear about addicts and addictions. Everyone shakes their heads and shakes their fingers or should I say points them in one direction or another, but do we really have a clear idea of what is going on? Just how did we get into this big mess?
I’ve practiced pain medicine as a specialty for the last 18 years. I’ve been a doctor for 30 years. When I was in training, there were Ethics committees meeting in hospitals to determine if it would be OK to treat terminally ill patients with around the clock pain medications. There were questions about whether or not we would “make those patients addicts” and did it or would it matter? Was it inhumane to do anything less?
We live to alleviate pain and suffering as physicians and medical providers. We live by the mantra, “above all, do no harm“ and we have to make difficult decisions depending on the patient and the situation they’re in. Well, I think we all know that it is generally accepted to treat terminally ill patients and to treat their pain to ease their suffering and allow them to have some quality of life in their final days, weeks or months. And then something else happened. Physicians started to notice that there were patients with persistent pain that was constant, chronic and not associated with cancer or a terminal illness. These patients and their pain were untreated or at best under treated. They were suffering and many were committing suicide to escape their overwhelming pain. Pain of this kind was found to be an unrelenting disease process in and of itself. A call to action was put out to raise awareness in the medical community and the general public, to change policies at the state and federal levels, mandating that these patients undergo early evaluation and intervention as well as continued follow up. Opioids, other medications and pain-relieving, rescue-type interventional procedures became a big part of treatment programs for these patients.
The Four Main Groups
When we stand in the present looking at our mess, we have to sort out what has evolved and determine who is at risk and for what problems. Generally speaking and understanding that there can be overlap among the groups, there are four main groups of patients/ people out there involved in it. There are diverters, substance abusers, people who take the occasional opioid medication to get through their day or night and then there are the people with pain who have been maintained on chronic, daily, often high dose opioid medications, alone or in combination with multiple other medications in a ‘polypharmacy of pain medications regimen. Diverters are people who get controlled substance prescriptions, most often opioids, under false pretense, and sell them or trade them. Some diverters use drugs recreationally or in an abusive way but the diversion aspect is criminal. Abusers have been known as addicts in the past and the term is still used quite frequently in the present but these patients are being called substance abusers and are said to have a substance use disorder because there is a spectrum of use/ abuse that exists and patients can fall into different places in the spectrum. Abuse, addictions, substance use disorder, whatever we call it, these patients have a medical problem that requires long term, affordable recovery programs that work on healing the brain, the body and the soul. These people are at high risk and need intensive treatment. The ‘opioid epidemic’ and all of the laws and rules being put into place are for these first two subsets of patients.
The occasional users are using opioids they way they should be used: episodically. They will not have problems with this type of use. The last subset of patients needs to wean and reduce all their medications because the data for chronic, high dose opioids is very negative. We thought it was the right things to do but research shows people continue to have pain and it even gets worse. There is some research that points to chronic opioids actually causing ‘opioid induced pain’, different from the original pain problem. They also have been shown to have negative effects on the heart, the brain and the nervous system, the GI tract, healthy sleep, and the psychological state of the patient, especially in combination with many of the other medications used to treat pain related side effects.
The push to get this compliant group of patients down or off their opioids and other medications if possible, has nothing to do with the laws and rules surrounding abuse and diversion. This group is getting caught up in the regulatory mess and think we are trying to reduce their regimens because of the epidemic. This is NOT the reason. It’s based on research showing it’s just not good for them. Research over the last 20 years shows that chronic, long term usage of high dose opioids, in combination with other medications or alone, has very negative and damaging effects on the cardiovascular system (heart and blood vessels), the nervous system (the brain and nerves), the GI tract (stomach and intestines/bowels), restorative sleep, the teeth and gums and most likely the connective tissue system (skin, ligaments, tendons). For these reasons, we have to get back to using opioids as a rescue in short courses and not as a mainstay of treatment. The good news is we can optimize medication regimens with a little effort and we can substitute non-medication neuroplasticity based treatments to replace many of them. Just in case you’re wondering how bad using chronic (high dose, in many circumstances) opioids can be, the next blog will talk about the effects of these medications on the heart. Stay tuned!