From a Doctor's Perspective: The Opioid Crisis in the Office Setting
If you follow the news, you know there is an ongoing opioid crisis in America, but how urgent is the situation?
Current deaths from opioids are higher than deaths from either breast cancer or colon cancer. There were 70,000 deaths from opioid drug overdoses in 2017. There were less than 40,000 opioid overdoses in 2012, and in 2005 there were less than 5,000.
The statistics are alarming for certain, but what makes this situation dire is that the profile of the opioid drug addict has evolved. Traditional thinking associates a drug user with being a street person, using drugs for pleasure, engaged in criminal behavior, so we tend to feel less sympathy or concern.
The new drug addict is often a law-abiding citizen who had an automobile, sports, or work-related accident, or surgery, and has experienced acute pain that was treated with an opioid prescription. The individual then struggles to manage the lingering chronic pain. The present habituation is directly linked to treatment with pain pills and, in many cases, the addiction is driven by healthcare providers.
Understanding chronic pain
Pain is a symptom with a purpose. Acute pain is actually a defense mechanism. It’s a signal from the brain that something is not right. You experience an injury and you must stop because of “pain” and re-evaluate what you’re doing and essentially allow damage control and repair. This process should usually take between four to seven days and during that period it may be appropriate (depending on perceived level of pain) for a doctor to dispense opioids and other strong pain relievers.
Then there is sub-acute pain. This pain is often present during the time of repair and it often involves inflammatory mediators. This is the most appropriate time to use anti-inflammatory agents, such as non-steroidal anti-inflammatory drugs (NSAIDS) . This process can take two to 12 weeks and during this period it’s appropriate to gradually increase activity and re-conditioning through the aid of physical therapy. Use of medications should taper off during this period
After a period of three months, tissue repair has taken place and any symptoms of pain remaining are considered chronic pain. It’s at this time that habituation to pain killers takes place since the sensation of pain is perpetuated for reasons other than the tissue injury or repair.
How does addiction occur?
It usually starts with an unexpected injury in what may be an otherwise healthy individual. He or she is referred to a specialist, who begins treatment appropriately with physical therapy, injections, and maybe surgery. A mixture of medications is often dispensed as part of the treatment plan. After the specialist finishes the treatment protocol, or further care by an insurance carrier is denied (or both), the specialist typically signs off the case, releasing the patient back to his primary care physician. This provider with the lack of any other skills in managing the ongoing chronic symptoms of pain, often continues to prescribe pain pills thereby allowing habituation.
It’s important to note that some individuals may be highly susceptible to addiction even after just four days of opioid medication use.
From the patient point of view, he just wants continued pain relief and feels justified in requesting multiple refills. These individuals need to understand that the role of pain medications is to alleviate acute, intolerable pain but that at some point, a lower level of pain needs to be managed with other drugs and therapies. Decades ago doctors were trained to “remove all pain.” The situation reached a climax when there was the case of Dr. Wing Chin. in June 2001, a jury in Alameda County found the physician guilty of elder abuse for failing to give a dying man sufficient medication to relieve his suffering.
That case is quite different from the day-to-day perpetuation of doctors simply renewing pain medication prescriptions. This philosophy has contributed to the opioid epidemic. We now understand that pain should be lowered to manageable levels, and the goal is to then use other therapeutic and non-addictive drugs to manage chronic pain.
There have been some cases of physicians and pain clinics taking advantage of peoples’ needs and engaging in abusive behavior that results in creating patient addicts.
The Chin case certainly spurred doctors to dispense pain medication for fear of being reported to the medical board. The vast majority of providers continue prescribing pain medications, pressured by patients who demand the drugs. With pain classified as the fifth vital sign, trying to wean a patient who desperately wants full pain relief is daunting. But it’s now a medical reality that we need to address (read part 2: Reasons for Overprescribing Opioids).
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