Treating Pain Has Become a Pain
How does our health system fix an overdose crisis while treating legitimate patients?
The official confirmation that the rock star Prince died of an opioid overdose is likely to refocus attention on an issue the country and Congress have been grappling with for some time.
“We have had overdoses in our emergency room [among patients who are] ages 13 to 69, in three-piece suits or cutoff blue jeans,” said one hospital executive.
Dozens of sad and tragic deaths are reported every day due to opioids — defined as both prescription pain relievers and heroin by the Centers for Disease Control and Prevention. The two drugs combined contributed to the deaths of 28,647 people in 2014, more than any year on record.
Many overdose deaths involve a prescription opioid — and the families of those who have been lost pray the deaths aren’t in vain. Family members are working with lawmakers on legislation that would improve addiction treatment, support drug overdose prevention strategies, and enhance emergency responder training.
Yet while talks slowly progress on Capitol Hill, disagreements remain over how to fund the proposed changes and whether or not they go far enough. So those who work in health care are taking their own steps to better manage the medicines that are prescribed and dispensed.
Nursing, pharmacy, and med schools are all in the process of revamping their training on opioids and prescription drug abuse. Continuing education initiatives are being examined for those already practicing. And from the top down, institutions seek to tighten security to prevent a diversion of pills, create task forces to address systemic problems, and encourage physicians to prescribe alternate lines of defense for pain management.
“We have had overdoses in our emergency room [among patients who are] ages 13 to 69, in three-piece suits or cutoff blue jeans. This knows no age barriers, no class barriers, no racial barriers. It’s just hideous,” said Peter Holden, president and CEO of Beth Israel Deaconess Hospital in Plymouth, Massachusetts, in an article for Hospitals & Health Networks.
One major challenge, however, is properly addressing the epidemic and properly managing pain without causing harm to legitimate patients. Pharmacists increasingly report having to turn away patients with valid pain therapy prescriptions because they — the pharmacists — can’t get the medicines anymore.
Hidden cameras caught nine different pharmacies in Florida denying cancer patients, among others, their prescription pain medications.
“We’ve created an entire group of patients that we’re starting to call ‘opioid refugees’ because the pharmacies they went to cannot get their medication anymore because they’ve been cut back,” K. Scott Guess, owner of Pain Management Pharmacy in Santa Maria, California, told the American Pharmacists Association in 2014.
Even when the opioid medication is available, legitimate patients are having a tougher time getting it. Hidden cameras from WESH-TV caught nine different pharmacies in Florida this spring denying cancer patients, among others, their prescription pain medications.
Florida Attorney General Pam Bondi, whose office has been cracking down on rampant abuse since 2010, said that while prescription drug deaths have dropped dramatically in her state, perhaps the effort has gone too far.
“Everyone means well, but sometimes the pendulum swings too far the other way,” she told WESH.
One hundred million people in the U.S. have persistent pain, said Dr. Jim Cleary, an oncologist and director of the global Pain and Policy Studies Group, a World Health Organization Collaborating Center in Madison, Wisconsin.
“Even if 5 percent of these people need access to opioids, that is five million people,” he said. “Globally, 80 percent of the world lacks access to opioids for pain relief. Balance is critical to ensuring access while reducing the risk of abuse and diversion.”
Sixty percent of opioid deaths are due to more than opioids — often multiple drugs are involved, including benzodiazepines (anxiety drugs) and alcohol, Cleary said. Methadone, which represents only 3 percent of all opioid prescriptions and can slow or stop a person's breathing, has accounted for up to 30 percent of all opioid-related deaths. Cleary said a number of states compel doctors to use it to save dollars within Medicaid programs, although few are educated in the complexities of this medicine.
Fentanyl, the drug Prince overdosed on, is the strongest opioid approved for medical use in the United States, rated as 50 to 100 times more potent than morphine and 30 to 50 times more potent than heroin, according to the National Institute for Drug Abuse. It's the go-to drug to dull the crippling pain experienced by many patients with advanced cancer.
But did Prince overdose on a medicine legitimately prescribed for his chronic pain? Or was it from the use of illegally produced fentanyl, now contributing to an increasing number of deaths nationally?
"We need to keep our focus on the ultimate goal of health care," said Cleary. "Opioids are an important medicine and we need to ensure that those who need them are not denied access because of the efforts in the 'War on Drugs.'"
This spring the Centers for Disease Control and Prevention released new guidelines for prescribing opioids for chronic pain for patients 18 and older in primary care settings. The recommendations focus on treating chronic pain — defined as pain lasting longer than three months or more after the time of normal tissue healing — outside of active cancer treatment, palliative care, and end-of-life care.
Primary care physicians are now advised to weigh non-medication alternatives, consider how therapy will be discontinued if a drug fails, and discuss the real risks of using opioids, before ever issuing a prescription. If one is issued, the CDC recommends the lowest possible dose for the shortest possible duration.
"We need to move away from the expectation of 'no pain' and toward a more realistic expectation that pain can be managed," said Dr. Kamshad Raiszadeh, an orthopedic spinal surgeon in California.
"As a society, this will further the conversation of risk/benefit with our interventions," he told LifeZette. "Sometimes the 'cure' is worse than the pain itself. Often, it's reasonable to expect people to function with a certain amount of pain. We don't like to hear this, but it's true. Living with a manageable level of pain is better than living with addiction."
Others say no matter what steps are taken to properly prescribe opioids, it won't be enough — more than half of those who use prescription painkillers for non-medical reasons got them "from a friend or relative for free," according to a 2013 study by the Substance Abuse and Mental Health Services Administration.
But even this piece of data is misunderstood: Treating a nasty headache with a single Vicodin that is "off prescription" is considered misuse.
"Not only do we need to educate clinicians about opioids — both the risks and benefits — but we need to engage with the whole community in this major public health problem and ensure appropriate access for these essential medicines, while limiting abuse and diversion," said Cleary.