The Grand Illusion
The number of deaths from opioid overdoses and misuse continues to climb. All sorts of legislative and regulatory proposals have been floated, almost entirely, from what I can tell, dealing with controlling or restricting the prescription and distribution of opioids. Most recently, the President has signed an executive order purportedly addressing the opioid crisis.
Almost none of these measures will work, just as the measures proposed to deal with illegal drugs have failed miserably. And these “new” approaches will fail for a very similar reason: They don’t address the real problems leading to opioid deaths.
According to the National Institutes of Health, over 100 million Americans suffer from chronic pain, and opioid-related overdose fatalities have doubled over the past ten years to more than 60,000 last year. While the NIH has recognized that pain and overdose deaths are related, and that medical pain treatment methods need to be improved, the underlying problem is incredibly simple… and presently not solvable for the majority of those suffering long term severe pain.
Opioids are the only legal way to relieve pain for most of those individuals suffering long-term severe pain. Continuous use of opioids requires higher and higher dosages to be effective and also makes users increasingly more sensitive to pain. In addition, chronic intense pain makes sleep difficult, and sleep-deprived individuals have even more difficulty handling pain. The medical profession has also been successful in “saving” people, at the associated cost of painful and chronic medical conditions.
While researchers are seeking other non-addictive pain remedies, so far as I’ve been able to determine, no non-opioid medication useful on a daily and long-term basis for a range of pain conditions has reached the stage of human clinical trials, and until something meeting those criteria is developed we’ll continue to face an “opioid crisis.” Restricting prescription painkillers will only drive people in pain to illegal drugs on a greater basis than at present, and that’s frightening, because overdose rates for illegal synthetic painkillers such as fentanyl are now approaching 20,000 deaths per year, an almost six-fold increase since 2002.
The problem isn’t opioids; the problem is pain. And very little of the rhetoric even acknowledges that.
It’s been a while since I addressed this on the blog – the better part of a year and a half, I think.
As an MD who prescribed opiods now and then, I will agree that the problem is pain. The problem is also people’s perceptions and what can be properly expected when a person has a chronic pain syndrome. And not all pain is the same.
Opiates are (if I can mix allusions) Pandora’s panacea for pain. They work very well for short term pain. Long term, they require higher and higher doses to have the same effect and eventually a person reaches a point where they reach very high doses and they have lessening benefits and withdrawal syndromes if they don’t take a maintenance amount each day. That doesn’t take into account the other effects of high dose opiates: constipation (minor, until you’re really suffering), urinary retention (kinda bad – and potentially very bad), and potentially fatal cardiac arrhythmias.
And that doesn’t include overdose.
So… what to do?
#1 There are other ways of managing long term pain. Managing doesn’t mean curing. True cures are uncommon. Physical therapy, Injections, TENS,
#2 Face reality. Most pain that people take opiates for don’t need opiates long term. Short term (1-3 weeks) then switching to anti-inflammatories and tylenol AND PROPER PHYSICAL THERAPY.
#3 Physical therapy is hard work and it hurts. And it works. And people wimp out all the time. The reality is that if a person can complete 6 weeks of proper PT and also CONTINUE THE EXERCISES periodically afterwards(especially for back pain).
#4 Remain active, by hook or by crook. Keeping the body moving and doing what bodies are supposed to do keeps them healthier and in less pain than bodies that are sedentary and not mobile.
Are these fair to people who are hurt and injured by things not their fault? No. Are these fair to people who have done things to themselves? No.
This is a hard subject. And people are in hard places because they are in pain. There are no easy answers. If there were, we would have already found them.
I always look forward to you blog posts, Lee – you raise such interesting questions. Wine Guy is quite correct, people do have different perceptions of pain. I’ve had several procedures under general anaesthetic but didn’t need any kind of pain relief after them – it was always low-level and tolerable. I’ve also had a colonoscopy without sedation (I had to be safe to drive home from it) and didn’t even need the laughing gas that was offered. But on the other hand I have a displaced spinal disc that is, I’m told, inoperable and doesn’t respond to physiotherapy exercises – and I can’t stand or walk erect for more than a few seconds without great pain. So I’ve learnt how to minimise that, and I don’t need or use any opiates or other drugs. So I have to wonder how many of the opiate addicts genuinely need pain relief and how many use it as a crutch.
I am also a “consumer” of pain medication, when proscribed and needed, specifically for temporary pain most often due to orthopedic operations (both hips and both shoulders have been replaced).
I have no medical training and have no basis for a medical opinion, however, I would offer these observations: after many of my procedures in the past I was proscribed opioid pain medication in very large quantity. Each time (procedure) I used the drugs to either avoid “unnecessary pain,” or to promote my ability to do the physical therapy I was also proscribed. I began “weaning” myself off the medication by slowly decreasing the dosage amount and/or interval as I could tolerate. It seemed to work well, and although I did experience a good deal of discomfort, I did was able to avoid debilitating pain.
More recently I have noticed there is an extreme reticence on the doctors/hospitals behalf proscribing any type or amount of this medication. I have had to deal directly with my surgeons to avoid being in “unnecessary pain.” I was stranded at one point, the night of a daytime procedure (shoulder replacement) without the appropriate medication proscribed in the middle of the night. As a result, I was given a non-opioid medication which shut my kidneys down due to an unknown allergy.
In other words, I think we went from feast to famine…throwing the baby out with the bath water.
Which brings me back to LEM’s point that the whole issue seems to be decided by politics, PR and, I suppose, fear of litigation. I have had to learn to live with pain on several levels, and believe that is my issue and one I can and do discuss with my doctors. I wish the decisions were left to the doctor and patient, with as little governmental interference as possible.
The discussion of opioids for pain relief reminds me of people who kick the nicotine habit. One person quits cold-turkey. “I just decided to quit, and never smoked again! If you had will-power , you could do it, too!” Another person tries, over and over, but never succeeds. Lack of will-power, or different genetics?
One person has high pain tolerance, another person doesn’t. Will-power, or genetics?
It is much more sensible to have alternative treatments for pain…for different pains and for different people. Unfortunately, some of the alternatives that are available require more than a prescription, and society does not seem to be willing to foot the bill.
This is a complex subject, with no simple solution. (And John Prigent, any pain medication is a crutch…but if your leg is broken, you use a crutch.)
Of course, Lourain. But if your leg is only bruised you don’t need a crutch, so perhaps doctors should be checking pain tolerance _before_ prescribing painkillers of any kind.
One person’s “bruise” is another person”s “broken leg”. How does a doctor check pain tolerance? For example, a surgical procedure that causes severe pain for one person might cause relatively minor pain for another. The doctor can ask, but only the sufferer can experience the pain.
By asking after the procedure, and after any anaesthetic used during it has worn off, whether any pain relief is needed. Which is what the medics did with me – it’s hardly rocket science.