Feb 28, 2019
by Vesta Copestakes
Do opioids have a place in treatment? Severe pain can be terrible and very debilitating. Extracts from the poppy plant have been used to relieve the distress from pain for millenia.
One of the downsides of the efforts to rein in the heavy use of opioids has been the difficulty in obtaining the medications by people who really need them. Clearly the pendulum had swung too far towards liberal prescribing patterns. Opioid overdose deaths are at stunningly high rates in this country, and although Americans make up only 20% of the world's population, we consume 80% of the opioids. There are many reasons for heavy opioid prescribing in the US — a medical system focused on quick treatments, a culture intolerant of discomfort, and the heavy influence of pharmaceutical companies in dictating medical care being a few of them. There is currently a major lawsuit against Purdue Pharma for high pressure marketing and ignoring concerns about addiction and overdose.
Approximately 10 years ago, it was required that physicians in California take 15 hours of training on the treatment of chronic pain.
Included was the notion that untreated acute pain led to nerves firing in such a way that they could become super-sensitized and then lead to chronic pain. So we were taught to treat aggressively, and to use a long-acting medication (like Oxycontin) as a foundational medication and then use intermittent short-acting medications throughout the day, for "breakthrough" treatment. It was considered poor practice at the time to treat with just short-acting medication due to the uneven dosing of the pain medicine.
Things are changing quickly. In the last five years, the amounts of opioids prescribed in our area have decreased by over 50%. The insurance companies are limiting amounts of medications allowed, doctors who prescribe opioids are being monitored very closely, and patients are having to jump through various hoops to keep taking them. I am seeing younger medical providers showing a reluctance to prescribe opioids at all.
Treating pain can be a very complex, labor-intensive enterprise. Successful treatment often involves physical manipulation approaches like massage and chiropractic, relaxation techniques, individual and group counseling, exercise/stretching/yoga, and some medications. The overall treatment environment needs to be supportive and accepting, and it seems to work best when the patient feels that they are being listened to, and respected. Marijuana has shown some benefits in some cases, but the jury is still out on how best to incorporate it into a pain treatment program. Many factors exacerbate pain and lead to increased debility. Stress, poor sleep, lack of understanding of family and friends, not being able to engage in other activities-- these all lead people to become preoccupied with the pain and the disability. If we look at improved function on medication, 'what can you now do that you couldn't do before?' rather than look for improvement of pain, it may be easier to see how the opioid medications can fit into a comprehensive pain program, and gauge what is working and what isn't.
● Some primary care doctors continue to prescribe chronic opioids, although fewer now and there can be scrutiny.
● Many doctors are not accepting new chronic pain patients.
● If you do try to change doctors, be aware that just showing up and saying you are out of meds will not go over well. Bring records. Assume you will be drug tested. CURES reports are required (looking at a Pharmacy data bank). Regular visits will be expected.
● Pain specialists may be a possibility.
● Buprenorphine is also a possibility, a medication that is used for addiction but also helps with some chronic pain.
● Preventing overdose in chronic pain patients is important.
○ Make sure you are getting Narcan prescribed and have it in your house, in the chance of an overdose.
○ Keep opioid doses as low as possible, and don’t take extra.
○ Co-prescribing with benzodiazepines can be dangerous.
As the pendulum swings back away from liberal prescribing of opioids for pain, some people will find they have difficulties getting medication that previously led to improvements in their lives. Shifting away from the opioids towards a more holistic approach to dealing with the pain is the preferred option at this time. Many patients who have been on high dose opioids for pain for many years (through no fault of their own) may have difficulties, and they can consider buprenorphine treatment. Switching to street opioids and heroin has been happening and is an unfortunate consequence of the current changes.
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