Fewer than 5,000 people died of drug overdoses in 1988, while more than 64,000 died last year. The seeds of this epidemic were sown and fertilized by a massive increase in the use of prescription pain medications. Four percent of the world’s population lives in the United States, yet we are using over 80% of the world’s pain medication. We do not hurt more than the rest of the world. We are just given a lot more opioids. How did we get here?
Recognizing the problem, the Centers for Disease Control and Prevention (CDC) revised guidelines for the prescribing of opioids for chronic pain. These recommendations are causing much consternation among prescribers, and outright fear among many chronic pain patients. Providers are wondering what to do with the many patients they care for who currently are on doses of opioids that exceed what the CDC has now listed as a dangerous amount. These patients are feeling fearful and even betrayed at the prospect of not receiving their usual pain medicine prescription. Any patient who is on regular opioid medications knows full well the discomfort of missing or even decreasing a dose. This quickly leads to major symptoms and pain.
When it comes to pain medications, pharmaceutical companies, the media and healthcare providers had been leading us to believe that any pain should be treated with whatever amount of opioids it takes for relief, and and that there was no unsafe amount. Pain has been construed as this evil thing that only a mean and uncaring person, facility or payer would ever suggest should be treated with anything less than complete relief. This is a principle that has been taught or implied in medical training for many years, and it has shaped the expectations of patients and families. Now, suddenly it seems the message is different.
I had an angry patient in my office the other day asking, “Why do I have to suffer just because those drug addicts are dying?” She had been referred to me after being told by her physician that he was no longer allowed by his employer to prescribe the amount of pain medication he had been giving her for years, and that she “needed to go see a detox doctor.” She has been taking over 600 morphine milligram equivalents per day, and she had been taught that this was safe. Pulling the rug out from under someone hurts. Even if the rug is on fire.
Prior to 1980, strong opioid pain medications were used primarily for cancer pain. In 1980, a letter published in the New England Journal of Medicine stated that opioids would lead to problems in less than 1% of people if used for medical reasons. This single publication, based on bad science, had a major impact on how our country uses pain medicine. This (dis)information has been used with great “success” by those that market the drugs. Now we know this letter was dead wrong, pun intended. It opened the door for the use of pain medications for any and all pain. It became accepted that there is no limit to how much pain medicine could be safely prescribed. A crusty surgeon who was one of my early mentors used to say, “Never let facts stand in the way of dogma, that’s just how it’s done.” Pain medicine prescribing succumbed to dogma.
Adding to the expanding use of opioids in the 1990s, the VA system began using a subjective 1 to 10 scale to measure pain in individual patients. A number that correlated to pain level was chosen by the patient, and subsequent treatment decisions were based on this number. This scale was adopted by hospitals after The Joint Commission, the accrediting authority for hospitals, began placing a high priority on patient satisfaction surveys. Hospitals quickly found that more patients receiving more pain medicine led to more patient satisfaction. Go figure. The resulting higher Joint Commission scores directly impacted funding for the hospitals.
In 2001 these patient satisfaction surveys became a driving force behind patient selected pain levels becoming the “fifth vital sign.” This vital sign contained no objectively measured data like the other vital signs, such as blood pressure, pulse and respiration. It was not based on evidence of improved treatment or outcomes. This evidence still does not exist.
We are now all living in the fallout of this perfect storm, with medical providers and patients learning (being told) “you can’t do that anymore,” referring to the amount of pain medicines being prescribed. Doctors have not been trained in alternatives, and patients have been trained that it is possible to get relief only from those pills. Physicians in my area are trying to wean to lower doses, and due to the nature of opioid physical dependence, this is poorly tolerated.
There are answers, and there are good ones. Implementing them requires a complete rethinking about pain by the medical establishment, payers and patients, however. This is occurring, but ever so slowly. Engaging neuroplastic change in hardwired pain pathways in the brain sounds involved. It is, but it works and it is evidence-based. Patients can and must become active participants in their recovery from pain, rather than passengers on the ride that gives more and more medications, numerous procedures, and other things that are done to the patient rather than with them.
This rethinking will take training of providers and education of patients. The benefits of this approach are available to nearly everyone, no matter the source or reason for their pain. For those interested in a deeper discussion of these more effective pain management ideas and methods, I would refer them to the books Back In Control by David Hanscom, MD; The Pain Antidote by Mel Pohl, MD; or Unlearn Your Pain by Howard Schubiner, MD.