Lately, the NYC Department of Health has been running ads on TV about the risks and sadness of addiction to prescription painkillers. They are good ads with an important message. "Prescription drugs destroyed my family," a mother says with great sadness. The message -- prescription painkillers now cause more overdose deaths than cocaine and heroin combined, and even when they don't kill, they can wreak havoc on people's lives. (1-2) Jobs lost, marriages destroyed, children neglected, depression and desperation -- all possible consequences of overuse of prescription painkillers. It is critical to get physicians who overprescribe these drugs to change the frequency and amount of their prescriptions. And it is critical to get people using these drugs for pain to be more cautious about how much they use and how they store medications that can easily fall in the hands of family members and friends.
But there is another important message to get out, a message that goes beyond the negative advice of don't overprescribe and don't overuse, a positive message regarding what can be done to relieve severe pain. Yes, doctors should prescribe more carefully, but they should also do a better job of helping their patients to eliminate, reduce or tolerate pain that otherwise can make life unbearable.
I first became clear about the importance of improving pain management after I posted two articles on this blog essentially delivering the same message that is conveyed by DOH's ads. (3-4) One was called "Prescription Painkillers: When Are They Too Much of a Good Thing?" In this article, my co-author and I identified eight signs that you may be addicted to or otherwise abusing prescription painkillers. There were numerous responses. A few thanked us or said they wished they had known what to look for before they became addicted. But most criticized -- even excoriated -- us. Of these, some could have been addicts in denial. But most were people who told us we couldn't possibly understand how much pain they live with. They knew they were addicted, but they said without painkillers they couldn't stand up, couldn't work, couldn't feed themselves or their families, couldn't think clearly, couldn't socialize, couldn't go out for some fun. These people believed, and they may have been right, that they needed painkillers to have a life.
Ironically, at about the same time the minor, annoying pain I had been living with for over a year became severe and disrupted my life. I could not drive. I couldn't sit for more than a short time, making working on a computer and socializing extremely difficult. The distances I could walk, eventually with a walker, became shorter and shorter. Teaching, meetings with colleagues, going out to dinner with friends became more than I could bear without taking a prescription painkiller. Because I was afraid I would become addicted, I lived with as much pain as I could tolerate and withdrew from many activities.
I was lucky. After two years and 15 medical professionals of many kinds, an MRI revealed a large tumor inside my spinal column. There was a cause and a treatment for my pain.
Not everyone is so lucky. One day while waiting to see a doctor at a highly regarded pain clinic, I chatted with a woman who appeared to be exceedingly anxious and depressed. She told me she was "at the end of her rope." (Think of the literal meaning of that expression.) She was, she said, addicted to opiates, which she began to take after an automobile accident that broke many bones and left her immobile for months. Now she could walk -- slowly -- and could get out for medical appointments, but she said she would not be able to get out of bed in the morning without painkillers. Even with them, she was not able to work because the pain made it impossible to stay focused. The emotional toll of unrelieved pain was clear. She hoped that this pain clinic would provide an alternative to opiates. Then she would go into rehab, she said. I marveled that she still had hope.
Yes, it is true that some people take prescription painkillers to get high, but a great many people who become addicted are just trying to live with pain. Modern medicine has a long way to go to help them.
The problem of pain has not gone unnoticed, of course. In fact, the Affordable Care Act (a.k.a. Obamacare) required the Institute of Medicine to do a study about pain and its treatment. The results were reported in 2011 and were quite startling. (5) More than 100 million Americans suffer from "chronic" pain, according to the report. That's one in three Americans.
Many find this hard to believe, as I did at first. But think about the number of people with chronic or recurrent back problems, arthritis, neuropathic pain in their feet, etc., and think about the number of ads on TV for over-the-counter painkillers. Isn't it plausible that one in three people live with pain?
Not, however, the kind, the intensity, or frequency of pain for which opiates are (or seem to be) necessary. Over-the-counter painkillers, stretching, exercise and weight loss can also relieve pain. People with chronic pain and their physicians should try these before opiates. When they jump to opiates too quickly or in excessive amounts, addiction is a real and unnecessary risk.
So, yes. Too many prescription painkillers are used when alternatives may work. And, yes. Physicians need to be far more cautious about prescribing them. The NYC DOH and other public health agencies are right about this. But there should be another dimension to their campaign. It should include an effort to help physicians and their patients learn how to address pain effectively -- to help them to have a life.
(1) Centers for Disease Control. "Prescription Painkiller Overdoses At Epidemic Level". November 1, 2011.
(2) CDC. "Vital Signs: Overdoses of Prescription Opiod Pain Relievers: United States 1999-2008" in Weekly Mortality and Morbidity Report, November 4, 2011.
(3) Friedman, M. "Prescription Painkillers: Protect Yourself and Your Family." The Huffington Post. January 31, 2012
(4) Friedman, M and Langosch D. "Prescription Painkillers: When Are They Too Much of A Good Thing?" Huffington Post, March 1, 2012
(5) Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. National Academies Press. 2011