Map of life expectancy at birth from Global Education Project.

Thursday, April 21, 2016

This won't end the opioid epidemic . . .

. . . but it might help. The CDC has come up with new guidelines for opioid prescribing in outpatient care which are heavily promoted in the leading medical journals. (The link is to NEJM, which proffers it for free to the subscriptionless rabble.)

The story of how we got where we are is pretty well known, I think. But I'll recap it for convenience.
Chronic pain (CP) is the most prevalent and expensive health condition in the United States, estimated to cost up to $635 billion per year in health care costs and lost productivity. Often pain is from osteoarthritis or other identifiable physical causes, but as I have discussed here previously, it can also be a malfunction in the brain-nervous system circuits that creates pain without an identifiable physical lesion. That makes effective treatment elusive. 

Obviously, having chronic pain can be a serious drag. It is associated with depression, social withdrawal, loss of employment. So, back in the 1990s a movement arose claiming that chronic pain was undertreated because doctors were too afraid to prescribe opioids. People claimed that when they were used to treat pain, people rarely became addicted, that there was little harm in long-term use, and that opioids were the magic balm that doctors were callously refusing to suffering people. No big surprise, the companies that make them sang the lead part in the chorus. 

So now we have an epidemic that is devastating communities all over the U.S., of overdose from prescription opioids, and of addicts who have switched to illicit heroin and fentanyl. Along with this comes ruined lives, crime, HIV and hepatitis C, and death. 

The truth is that long term opioid use for chronic pain does not work. Ever-increasing doses are needed to maintain analgesia, with ever-increasing side effects, and eventually complete failure. In fact people who use opioids long-term may have more pain than people who do not. And yes, it is addictive, particularly as doses increase. The new guidelines make prescribing opioids for chronic pain in people who are not terminally ill a last resort, but if you look at the facts, it probably shouldn't be a resort at all. If you have acute pain, from surgery, or breaking your leg, you might want to go for three days, seven is really stretching it. But longer-term use really doesn't make sense for anybody. 

I had surgery and I took opioids for one day, then switched to high-dose ibuprofen, which was perfectly adequate. I took omeprazole concurrently to prevent stomach upset. Unfortunately, for chronic pain NSAIDs don't really work either, and they can have serious side effects if taken long term. There really isn't any good pharmaceutical option for most people. (A minority seem to respond well to gapapentin or similar drugs, but you need to get lucky and they can also have weird effects.) The most important thing is not to give in to it -- stay active, overcome the natural reaction that the pain signal is telling you not to use the affected limb, lose weight if that's a problem for you, and stay involved in your usual activities. It may well get better in time, but in any case, you can live positively. Dope is not the answer.


Patricia Leupp said...

Admin, if not okay please remove!

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Lissette said...

I agree with what you have to say in regards to opioid usage. As a medical professional within the specialty of oncology/hematology, I have come across several clients that have been on controlled substances to relieve pain, whether acute or chronic. As you stated over time their bodies begin to adapt, and tolerance to the medications they are on begin to build leading to higher doses or more potent pain medications like IV Diluadid. Of course, oncology/hematology patients are on pain, I have no reason to believe otherwise, however, I believe that they are started at many times by physicians on a more potent pain medication, and then have difficulties switching over to anything taken by mouth or simply don't feel the same "rush" of relief of pain that they do from medications intravenously. I think it's fair to say, that regulations should be placed on the beginning medications as well as leveling up from there, on pain medications, to not only diminish tolerance, but prevent addiction.