There has long been recognition in the U.S. that clinicians tend to under-treat serious, and especially chronic, pain. This problem tends to become most recognizable when the source of pain is objective, such as cancer, and when concerns about the consequences of pain medication use -- such as addiction -- are most questionable, if not downright silly.
When someone is likely to live for only a matter of months, for instance, the possibility of developing a dependence on narcotics is inconsequential, especially if it is the price to pay for a tolerable level of comfort. This concept has been fully embraced and best practiced by hospice, where the provision of comfort is the top priority. But there certainly are reasons for reticence about use of narcotic pain killers in general, even if those reasons unfortunately do spill over into areas where they do more harm than good.
Narcotics, like a number of other common drug classes, are "habit forming," meaning their use propagates their use -- and potential abuse. There are several elements to true addiction, the most notable of which being that whatever you needed the treatment for in the first place, you wind up needing it just because you need it; the dose for a constant effect tends to rise over time due to a phenomenon called "tolerance," and there is an unpleasant, if not overtly dangerous withdrawal syndrome if the "treatment" is stopped.
There are, of course, dangerous effects of such drugs unrelated to addiction as well. Narcotics and sedatives are both "mind altering," dulling mental clarity and potentially impairing judgment. Narcotics slow activity of the GI tract, causing constipation. More ominously, they can depress both blood pressure and respiration -- a potentially lethal effect.
Coupled with these harms is the unfortunate experience every doctor-in-training has with so-called "drug seekers." One of the more common ploys used by addicts to get narcotics is to go from ER to ER, shift to shift, with a different story each time about a severe pain for which only narcotics will do.
Working sequential day and night shifts in an ER some years ago, I encountered the same drug-seeking patient who, not remembering me (those "dulling mental clarity" effects, presumably), used totally different stories in the span of 12 hours to justify a narcotic prescription. This was one of the rare cases where any doubts I had about a scam versus real pain were fully resolved.
Since it looks bad on a doc's resume to be giving out narcotics just because somebody wants them, we learn -- for better or worse -- to be suspicious, and cautious. But there is an inevitable trade off: the better we are at keeping narcotics out of the hands of those who, in principle, shouldn't be getting them, the more we risk denying them to those who certainly should.
And now, the plot thickens with a recent report generated by the Centers for Disease Control and Prevention, and the Substance Abuse and Mental Health Services Administration showing that the number of emergency department (ED) visits involving non-medical use of prescription opioids increased 111 percent during the most recent five-year period. As of 2008, annual emergency department presentations for misuse of sedative and narcotic drugs combined, mostly by adolescents and young adults as one would expect, greatly exceeded 500,000. During this same period, emergency visits related to illicit drugs were fairly stable.
So we find ourselves between the proverbial rock and hard place. We often fail to treat chronic pain adequately, yet the very drugs we prescribe to relieve pain wind up causing it -- not to mention the threat of death -- in others. What's the answer?
I can't say that I have one; it doesn't seem that anyone does. But I do have ideas, and it's clear we need to do something.
For one thing, physicians prescribing these drugs need to let their patients know about the potential for abuse. Narcotics and benzodiazepine sedatives (i.e., drugs in the same class as Valium) in the home are a bit like a gun in the home; used in the wrong way by the wrong people, they are lethal. They should be kept safely locked out of the reach of anyone for whom they weren't specifically intended.
Parental awareness, and vigilance, are essential. Parents of teens and young adults need to know the magnitude of this problem, and the booming black market for pilfered prescriptions. Forewarned is forearmed.
Educational programs for the young that have traditionally focused on the hazards of illicit drugs, such as DARE, need to keep up with the times. Prescription abuse seems to deserve equal coverage now. Ideally, a more realistic sense of the danger of these drugs might dissuade at least some young people from putting them to recreational use. Working against this, I suspect, is the notion that if something is 'legal' it must be safer than something that isn't. Alas, this is utterly untrue; a synthesized narcotic considerably more potent than heroin is perfectly legal by prescription, for example.
The most fundamental solution -- the solution most fraught with both promise, and peril, in my view - is to have fewer of these drugs in circulation to begin with. The promise is obvious: if there were fewer prescriptions for pain killers and sedatives, there would be fewer opportunities for the abuse of these drugs. Fewer people would ever encounter them.
The peril, though, is that people in pain would be denied needed treatment, and that is not my intent. Rather, we can, and should, do a better job of treating such needs in other ways.
Pain can often be treated with physical therapy, massage, biofeedback and so on. Colleagues and I, for instance, published a study of massage therapy for osteoarthritis of the knee, showing remarkably good and persistent effects; we are currently completing a follow-up study.
Pain often subsides considerably just by improving sleep, which is often deficient, generally neglected in clinical encounters, and usually fixable when addressed. Anxiety can be treated with mind-body techniques. But these interventions take more time and effort than a reflexive prescription. The always rushed, on-the-fly system of health care we have cultivated tends to favor, and foster, the expedient approach. But if a little more time for thoughtful approaches to pain management means, among other things, fewer overdoses to treat in the Emergency Department, I would hope all concerned could agree it is time well spent.
Drugs prescribed to alleviate pain represent good intentions; but they are subject to the unintended consequences of bad use. It may seem as if we are damned if we do dispense drugs to treat pain, and damned if we don't. But we should be able to implement an array of strategies in which we all have a role to play -- among them better use of alternatives to knee-jerk pharmacotherapy -- so that prescription pads reliably do more good than harm.
Dr. David L. Katz -- www.davidkatzmd.com
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Another big problem with requiring prescription pain medication is the way others tend to view me when they find out that I am taking them. People view others who require the pain medication for something, that they view is simple arthritis as just drug seeking addicts and not people who have an actual need for them. Of course it doesn't help that they are watching these news reports that are on 24/7 about this actor dying from the abuse of them or this actress worried she is going to die if she is taken off her's before she goes to jail.
Once the bodies own internal pain suppression system is completely shut down, those who use angalgesics become extremely vulnerable emotionally, this is called an Opiate affect, and is in many ways responsible for an addicts continuing inability to function, once they no longer take drugs. It takes years, and years for the internal pain system to start working again if ever, and taking any analgesic medication can block any return to normalcy.
Like it or not pain is the bodies attempt to healt itself. Suppressing pain, ensures that pain will increase, as the body has to increase it's efforts to heal itself, and this means more pain.
The converse is also true the more you avoid analgesics the stronger you become, the healthier your immune system becomes. Let your immune system heal you.
Feeling feelings hurts but not feeling will eventually kill you.
Just break down and cry, let it happen.
Anesthetics, are not necessarily pain killers. This is why you have an anesthesiologist when your in surgery.
This article was talking about anagesics that people take for pain.
But since you broached the subject, surgery, has often been performed without any pain killers, using acupuncture and hypnosis instead.
However back to the point, when someone relys on pain killers its a one way street, that ends in tolerance, the shut down of the bodies internal pain killers, heightend sensitivity to pain, increasing amounts of pain as healing impulses continue to try and break through anagesic repression, and immune system repression leading to an increase in dis ease.
In short, at the end of your run, nothing will stop the pain from hurting, and now since you don't have internal defences you have no way to feel it. A dead ending.
You sound misinformed. Please don't use fictional tv shows as some way to lay blame. I have never seen a pain clinic with a pharmacy attached. It is hardly easy for those who use legitimate means for legitimate reasons to get vicodin or xanax. The honest people with real problems suffer.
I see you mention pot. I'm getting tired of this (not necessarily you, but other people who have commented promoting pot as a cure-all). I want it to be legal, but it is not an effective cure for pain for all people.
I hope the best for your daughter and am sorry to hear about her's and your troubles.
http://www.tampabay.com/news/politics/stateroundup/new-law-may-crack-down-on-florida-illegal-prescription-drug-market/1011527
Its so easy to get prescription drugs here, I can't even explain it to you, it's a huge cash cow and some folks are getting very wealthy causing alot of misery. I'm not misinformed, I'm living it.
When he did see them he was high all the time and he did not take care of them. The came home in soaked diapers with rashes and in their pajamas and I finally had enough when my son was sent to the emergency room for a allergic reaction to something he clearly . I am not against people who think pot is beneficial to help their pain, and while it is much less addictive then opiates it can still be addicting to those who suffer from addictive tendencies.
The best part though of pot is all the people saying how harmless it is only further justifies its misuse. When you say pot hasn't destroyed anybody's life I beg to differ. Any drug in the hand of people who cannot handle it, abuse or overuse it- is not a good thing.
Nonetheless, a new day is dawning, finally, and we can move on into practical effective pain management that does not further debilitate the patient and society as a whole. One can not make a T-shirt out of a vicodin plant.
http://health-actuary.blogspot.com
Nonetheless, a new day is dawning, finally, and we can move on into practical effective pain management that does not further debilitate the patient and society as a whole. One can not make a T-shirt out of a vicodin plant.
I from time to time, sometimes lasting a year or more, get tension headaches. I don't mean an annoying throb, I mean an ax being driven through my skull. (I have a mouthguard, have done acupunture and biofeedback which only lasts as long as I can concentrate lying down on the pain). I cannot tolerate the popular vicodene, vomiting withing 20 minutes of taking one.
I HAVE to have fiorinal with codeine on hand (aspirin instead of acetametaphene) AND caffeine and yes a somewhat low dose of codeine. I believe the caffeine in this very old pain killer keeps me from getting sick to my stomache as it RUSHES the narcotic quickly to the target (my head). I shutter at the thought of a discontinuation; not sure what I'd do. I can go days, weeks, even years with NO huge headache, then a swarm hits
For me, these days, marijuana just doesn't work (I did get a medical prescription a year ago when undergoing cancer treatment..just didn't work). Big Pharma created the beast that is oxycodone and vicodene. It's the world we live in. I'd rather see addicts (yes very say) get their stupid drugs for a high, than deny even ONE terminal or very ill person be denied a sanity saving dose of painkiller. Cancer made me scared to death of "caution" in use of narcotics. If it comes back, and I don't live in a state with the magic kool-aid. I want to be drugged into a comotose stupor, and have my medical directive stating such!
Most emergency departments are not set up to provide the level of care that chronic pain patients require for primary on-going care.
The lack of adequate access to primary care certainly is contributory; as is lack of availablility of specialized pain management.
JCAHO made pain management a national patient safety goal because no provider group in the US seems to treat any type of pain very well.
Recently JEN published a nursing study of Sickle Cell patients experiences with pain management. The results are heart breaking. Whether we as an industry want to admit it or not; there is a racial component to effective pain control.
The love affair our industry has with Press-Ganey, and the current medico-legal environment we work in has perpetuated, among providers, attitudes of incredible ignorance about pain perception. That 1 out of 10 rating scale is worthless.
Both patient and provider education that is evidence based, acurate outcomes measurement, access to more appropriate care venues will help. Until we as providers of care own our part in the problem, none of those things will be as effective as they could be.