Oh, I agree, we really created a problem with overprescription of opioid painkillers, but could it be that the pendulum has swung too far in the other direction?
Anecdotally, I can tell you that it’s pretty much impossible to get a prescription for painkillers these days. I mean, I had an accident where I got to look at the inside of my knee, and had emergency surgery, and couldn’t walk right afterwards for years, and I was sent home from the hospital with a recommendation to take Tylenol for pain.
And I know a ridiculous number of people who are in the same boat. A movie cameraman I know had a light fall on him. A movie light, must have weighed more than 50 pounds. Part of his arm was basically turned to jelly. He, too, was sent home, after much surgery, with Tylenol as a painkiller. And there are others.
There is a problem, to be sure. But maybe the answer isn’t denying pain relief to those who really need it.
Thank you for your insightful rebuttal of the evidence that I presented from the CDC and HHS. You are clearly the superior orator here, so I will tuck my tail and leave. :rolleyes:
Problem is, your cites end in 2012, which was before the 2014 rescheduling of hydrocodone containing products and the 2016 changes to prescription guidance. From 2014 to 2015, the heroin overdose rate increased by 20.6%, and “Some of the greatest increases have occurred in demographic groups with historically low rates of heroin use: women, the privately insured, and people with higher incomes.”
The dots have not been completely connected yet, but they’re marked with red flags and neon lights.
It’s extremely difficult for the medical community to admit that we did this. We listened to the lies of drug companies and got people hooked on painkillers for uses that they are not actually safe and effective for, and we created a demon.
Worse, we don’t know how to fix it. If we restrict opiate prescriptions to the clinical situations that they’re actually good for (and relatively safe for), then we leave tens of thousands of people with uncontrolled pain. Because while Tylenol and NSAIDS are great, they’re not enough. Physical Therapy, weight loss, and quitting smoking are interventions that would help a lot of people reduce their pain, but they’re hard, and people don’t like to do them. Massage, acupuncture, and exercises like yoga, Pilates, and Tai Chi might help many as well, but insurance doesn’t pay for them, and they’re time intensive and require a lot of effort (and being able to leave your house.)
The truth of the matter is: we don’t treat pain very well. Where we really need to start (in my humble opinion) is by admitting to our patients that just like there’s no cure for diabetes and no cure for ALS…there’s often no cure for chronic pain. We can treat it, but even our best efforts will only improve your quality of life while you deal with this disease process for the rest of your life. The good news is, in just the last year, I’ve observed a lot more patients whose doctors are finally being honest with them about this. And the overwhelming response is one of relief that they’re no longer being gaslighted, compared to the overwhelming frustration I’ve heard in years past.
So it is progress when my PCP told me that relieving my pain is not her job?
I am looking at a not-too-distant future where I am connected to a dialyzer for over half of my “life”, as well as a CPAP which has started to whistle when I exhale.
Does this sound like fun yet?
Now, my “Doctor” (who hand-waves everything I say) tells me I will be in excruciating pain while this is going on.
I used to have a wonderful exercise routine - this piece of junk house needs everything fixed or replaced.
I could do that stuff when I had 45mg MS Contin. On 15 mg, I lie in bed and pet my cat.
I will NOT stick around for that scenario to play out.
And the CDC lumps all opioid users as a “problem population”.
BTW: the “Tattle-tell Database” is now up. It tracks every Sch II prescription in the country.
I wonder how long the DEA will spend cross-referencing all the “narcotic seekers” who have multiple doctors and are/were getting the 'scripts filled at different pharmacies.
Well, it was a fun life for a while.
Then it became untenable
Then it got a bit better; it could be made to work after a fashion.
I have a problem with the “while not pain free” part. Are you saying that one can’t be functional at all while on a high dose of opiods? It seems to me that addicts can do quite a lot of things. Also, what about people who would prefer less functionality and less pain? Shouldn’t the decision be left to them?
My spouse has had chronic back pain every day of his life (birth defects can be such a bitch). He has a lot of ways of dealing with it, including distraction and some mental exercises. Mostly, he uses Tylenol. At one point he was using an opiate for the worst days, but the first time the Feds decided to make prescribing more difficult he went off it without difficulty.
Yes, people CAN learn to live and function with chronic pain, including marching in street bands, scuba diving, hang-gliding, being an entrepreneur… all things my spouse has done. But then, no one ever promised him he’d ever be pain-free and he learned early on that taking enough medication to be as nearly pain-free as possible had other consequences he found just as troublesome as chronic pain. He found a compromise between “no drugs at all” and “zoned out” that works for him. (Well, until he recently developed bladder cancer, that’s been a tough one, but that’s malignant pain, not chronic.)
Maybe we should have been focusing on optimizing function rather than “rendering the patient free of all pain” or “preventing addiction at all costs”. Of course, “optimizing function” might wind up being more actual work than taking pills.
The ‘functional’ comment refers to their ability to function despite the pain, not functioning with opioids. Opioid users do become habituated and can function at a very high level on their meds.
As for the patient deciding the right dose of opioids for them, well, our society has presently decided that the rise in the death rate outweighed individual patient rights to choose opioids.
I do tend to think the pendulum has swung too far, and that people with significant acute pain are not getting enough access to opioids these days. And many folks who could benefit from and use opioids safely now can’t get it.
Of course I never got on the ‘more opioids’ bandwagon in the first place, fearing that we’d see a lot more deaths and a lot more active addiction.
As for all the docs blaming the DEA, and the government for their inability to prescribe narcotics, well that’s BS. The docs just need to make sure they carefully and correctly document the patient’s signs, sx, treatment plan and then proceed and prescribe rationally and document that too. I still prescribe opioids regularly, including for some select folks with chronic pain. It takes more work, more time, etc. And in the private sector, the reimbursement is not good for taking that time. And with the clinic administrators keeping tabs on the docs to see how many narcotics they prescribe, and putting pressure on them to prescribe less, many docs just stop doing it.
BTW, to me, malignant pain is pain from an actively destructive process, something actively destroying tissues, such as an erosive/obstructive cancer, infection, or inflammatory process such as rheumatoid arthritis. Certain diseases can be pretty destructive in their end stages too, with a lot of difficult to treat pain. I do not count degenerative, or osteoarthritis as a destructive process, as it unfortunately comes from basic wear and tear in most cases.
QtM, prescribing opioids for over 3 decades, and seen a lot of trends come and go in that time, but none more destructive than the recent “Pain is the 5th vital sign and must be treated, and opioids are safe to use for it” movement.
Yet another neat, simple wrong solution You must be a real hoot on death marches. Why do people have pain issues in the first place? Because they can’t walk, or even move one or more body parts at all without pain. Can’t think straight due to blinding headaches, or any of countless other things that render people in a state of REDUCED FUNCTIONALITY due either primarily to or as a secondary symptom of pain.
Quadgop is absolutely correct in blaming the medical profession. When it’s all said and done there is nobody left to blame but doctor’s unable to “do no harm” except to leave a patient in pain. Maybe they will get down to the business of treating pain management as something thay cannot hand-wave away now that opiates are universally recognized for not being the panacea once thought.
Me, I’m with Broomie for optimizing function over making the patient pain-free. Also over avoiding opioids to prevent addiction. We got into trouble in the first place because the emphasis was on freedom from pain (an illusion, all life has pain). We’re now in the mode of preventing addiction and deaths. Pain patients tell me they want to be able to do things, not that they want to be pain free. And many of them are quite happy if they can achieve their reasonable goals, in the face of their pain. Sometimes that means using opioids. Often those goals can be achieved without them.
And it starts with honest conversation with the patient about what *their *goals are. Which, of course, most doctors aren’t paid for. They’re paid to DO things, not listen.
But if we can establish that your goal is to have two almost totally pain free days a month so that you can go do your grocery shopping and pay your bills and paint your ceiling, and it’s totally acceptable if you trade that for six days spent in bed recovering, then we can probably make that happen. IF you’re really dedicated to that and won’t take your opiates the other 28 days of the month and build up a dangerous tolerance. (And if you have a person with you to help you paint and make sure you don’t fall off the ladder, because your balance will likely be wonky.)
The stupid Joint Commission’s insistence that we get people to pain free, and pain free all the time, is the problem. That’s just not possible with the limitations of modern medicine. But it got doctors and patients focused on an unattainable goal. It’s like making a goal that a diabetic can eat a whole cake every day and use some insulin and not get nerve damage. It’s not because we’re trying to be mean, it’s because we don’t have the magic pill to make it happen.
Someday, we may have a new kind of pain medication that makes that possible. Today, it isn’t,
And it never will be as long as the pharmaceutical companies are raking in profits from opiates. Why aren’t doctors, the AMA, the CDC, the NIH, whoever, clamoring for more research into pain management? Either new drug research or otherwise? Exactly what is being done apart from the status quo: Get opiates under very limited circumstances “if” we think you need them, otherwise tough it out. And OBTW, we are liking the need for opiates less and less as the government makes using them increasingly difficult.
Thanks a bunch, healthcare industry and big gubmit.
The drug companies aren’t making much money on opioids these days.
The physicians, AMA, CDC, NIH, and countless other private and public health organizations are working on finding better meds, techniques, treatments for pain. But it’s complicated. The devil is in the details. Many ‘breakthrough’ drugs and techniques were brought into play, only to find they either were ineffective, or their risks outweighed their benefits.
Doctors and nurses really want to help their patients. Otherwise the opioid epidemic wouldn’t have happened. Seemingly credible academic and research physicians came to us and said “this approach to pain using long-acting opioids works! We have evidence!” So many jumped onto the bandwagon and hoped for a great decrease in suffering. Instead we saw our patients, or their family members die from using the medications we gave them in good faith, and in hope for their improvement. Ever do your very best and find out you didn’t help someone, but instead contributed to their death? It’s not a good feeling.
So the quest goes on. Until we find better treatments, there will be continue to be a lot of suffering, some of which will inevitable and some of which would be avoidable with the right interventions.
To be blunt, my spouse has chronic pain because around 8 weeks after his conception things went wrong and his spine nerves and vertebrae failed to develop properly. Between that going awry, and the necessary surgery to save his life and enable him to walk at all there’s a crapload of scar tissue, abnormal nerve routing, and other happy horseshit to contend with. He has pain every day of his life regardless of whether or not he moves.
He had two choices in life: he could sit or lie down and hurt, or he could get out there and do things despite hurting. Funny thing, though - pain is NOT binary, it’s not full on or full off. There are greater and lesser degrees of pain and, amazingly enough, you CAN move your painful limb, or walk on it, or work with a headache if it’s not TOO painful. One the techniques for dealing with osteoarthritis is to keep moving - if done properly it increases function helps control or even slightly reduce (but not eliminate) pain. Strengthening muscles, which requires moving, can stabilize a painful joint and control or reduce pain but you’re going to have to be able to tolerate some pain and not simply give up entirely at the first sign of it. If you stop doing things because a joint hurts then the muscles around it weaken, the joint becomes less stable, and things can get worse whether you’re talking about an ankle, a knee or spine.
So, guess what, sometimes moving that painful limb, even if that causes pain, actually IS the best thing to do.
Knowing what is acceptable exercise or too much is sometimes tricky - that’s why if you’re having a problem you should consult a trained professional.
Personally, I’m blaming my insurance company that doesn’t want to pay for my spouse’s extended release morphine for his bladder cancer rather than the oncologist who is battling the insurance company to get it to pay for the morphine she’s prescribing. Folks shouldn’t look for any easy single agency to blame.
The problem is that there isn’t a good answer for most chronic pain. Acute pain and opiates, yep, that seems to be a winner but chronic pain is a very different problem that often requires a multi-prong approach. I known a former college athlete who finds alternating hot and cold for his destroyed knees combined with non-weight-bearing exercise like swimming works best for his chronic pain. My spouse prefer to be drug-free during the day, only using even Tylenol for sufficient relief to get to sleep at night but as I said he has practiced several mental techniques for dealing with pain and being functional despite it. That doesn’t work for a lot of people because learning those techniques is work and takes time and dedication to really get use out of them. Pain that comes from inflammation might be better treated with anti-inflammatory than opiates. In other words, there is no single answer and SOME of those answers can work but require more work from the patient than simply swallowing some pills. And Americans, by and large, don’t like having to work like that or learn to tolerate some level of pain rather than deal with harmful side effects from drugs that aren’t really suited to their problem.
Or haven’t you heard of aspirin? Ibuprofen? Acetaminophen? And so on… those are quite adequate for many types of pain, or in conjunction with opiates for pain (my spouse currently reports he gets significantly more relief from the combo pill of morphine+acetaminophen than from a higher dose of just morphine alone. And that’s for the Big Baddie Cancer Pain). Migraine headaches have their own suite of drugs, including botox of all things which some find quite effective. Some anti-seizure drugs can be useful for certain types/causes of pain. There ARE alternatives out there, both pharmaceutical and non-drug. Just because you aren’t aware of them doesn’t mean they’re non-existent.
Pain is actually a pretty complicated sensory mechanism. Like other complicated systems, it can go wrong in multiple ways, each of which may have a different solution.
What makes you think they aren’t? Really, the first person to come up with a truly safe long term effective chronic pain med is going to be a gazillionaire. Pain patients are a huge population looking for a new drug.
One of the classes of meds that’s freaking out some of my pain patients is antidepressants. They think when the doctor prescribes them Celexa or Amitriptyline that the doctor thinks they’re crazy, or depressed, or that their pain is all in their head. No. Actually, some antidepressants TREAT PAIN. No one’s entirely sure how, but there are a couple of theories, and they treat pain whether you’re depressed or not. We call them “antidepressants” because that’s what they were discovered to do first, but if the timeline had gone differently, we might as well have called them “pain medicine” that turned out to be effective at treating depression, too.
The problem with any of the drugs, NSAIDS, opiates, anti-depressant cocktails, etc. is none of them are good long term. You can’t just keep taking Ibuprofen by the gram for years and not expect to die of liver failure. Pick any of the other alternative pharmaceutical meds and there is a similar unpleasant side-effect story to be told. Rotate through cycles of different things to increase your odds? No thanks.
No idea. It’s not legal in my state without a card, and I don’t have any patients with cards, so it’s not something I’ve educated myself about. It’s on my list, but right now I know nothing that can’t be googled.
Not as much as I’d like to be able to. It’s pretty heady stuff. The basic explanation I know to give my patients (which may be oversimplified to the point of error) is that they prevent cells in your brain from reabsorbing (that is, they inhibit the reuptake of) some of the chemicals your body uses naturally to reduce the feeling of pain (tricyclic antidepressants - biogenic amines like norepinephrine (NE), as well as serotonin, SSRIs - serotonin.) With these chemicals more available, your body does its own job at not feeling pain so much. That we’ve known for a while, at least since the 80s. What we’re finding out more recently is that they also work locally - at the site of the pain, by several methods, including reducing inflammation by blocking histamine production.
Yes, as I said, we don’t have a good answer for chronic pain.
My dad the pharmacist used to tell me that if it was strong enough to help you it was strong enough to hurt you. All painkillers have side effects. All of them.
Yes, sometimes rotating between different pharmaceuticals can either prevent or mitigate the damage.
Sometimes using other methods can reduce the amount of pharmaceuticals you need - but as I have said, that might require work on the part of the patient.
Sometimes a multi-prong approach is the best thing to do.
Sometimes you have to accept a trade-off.
In other words, there is no one answer. Sorry if that isn’t satisfying, but reality often isn’t.
