Abstract
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In 2013, the Centers for Disease Control and Prevention issued a fact sheet titled, “Prescription Painkiller Overdoses: a growing epidemic, especially among women”. Some of the staggering statistics included 18 women dying daily from prescription painkiller overdoses in the US in 2010. Between 1999 and 2000, 48,000 women died from the same overdoses. While more men died of the same type of overdoses in 2010, the sharpest rise was seen in women. 4
It is wrong to blame the initially well-intended plans of the VA and Joint Commission from over 15 years ago because many patients, particularly the elderly and cancer victims, were suffering from unrelieved pain. The current tighter regulations placed on the prescribing of opioid analgesics by our government agencies have also created consequences. Patients who actually need opioid analgesics are angry that their pains are being undermanaged. Our residents and housestaff are often caught in a bind between patient demands for particular narcotics and what they believe to be appropriate. There is perception bias between what patients believe works for them, even when two drugs are similar in efficacy. Patients with legitimate prescriptions usually have to shop multiple pharmacies until they find one with sufficient amounts to dispense. My neighborhood pharmacy was robbed at gunpoint during the daytime of its opioid containing medications including cough medications, which were locked away. With the chemical similarities between heroin and opioids, some communities have observed more heroin abuse tragedies purportedly due to difficulties in obtaining prescription narcotic medications. 2 A trap has been created with two points of entry; dependence on or even addiction to legitimately prescribed drugs, and addiction to like-compounds. The sad fact is falling into these traps can be through both legal ways and illegal ways.
Our bariatric patients are not immune to the opioid trap. There are patients who come to the office already on opioid pain medications, typically for musculoskeletal pain. Without pain control, they cannot function productively or go to work. A patient I know described the feeling of someone violently pounding inside of her skull because of an inoperable acoustic neuroma (benign tumor). On her many good days, you would never know she had the problem. We also prescribe these medications after surgery, and there is really very little information on what is the right amount; too much and you risk overuse or the medications landing in the wrong hands; not enough and you will be called multiple times after discharge for more pain medications.
There is no quick solution. Several government agencies are already making this issue a top priority. Most of the burden is placed on the prescribing physician to control the distribution of these medications. We can and should do better than to limit our prescriptions. Those of us in the practice of caring for weight-related issues are accustomed to a much more comprehensive approach to providing care, and we should take a lead or at least have a framework for our practice. Some broad points to ponder over:
1. Our professional schools need to teach pain management with a 360-degree perspective. The best curriculums are a strong blend of science coupled with real life patient experience. The curriculum should include psychology of dependence, tolerance and addiction, as well as addiction rehabilitation. Case discussions and simulations are great tools for adult-learners. I remember a patient coming into my medical school class at Des Moines University telling us about his pain management needs during a sickle cell crisis. I remember that particular class better than any of the talks on mu-receptors. Our unacceptable alternative is to let the drug manufacturer tell us the upsides and minimal downsides to their opioid medications. 2. Physicians in practice should become current on opioid prescription practices and formulate a plan for the practice. An interesting study by the Georgia Composite Medical Board showed that a significant number of physicians who read the book Responsible Opioid Use: A Physician's Guide (Fishman 2007) changed the way they prescribed.
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Again, if you do not have a current framework for managing pain, you will rely on someone else to tell you the information. 3. Invite other physicians who have expertise in pain management into your practice. They know much more than just prescribing a controlled substance. Many of them understand nuances of non-narcotic medications, use injection modalities with imaging techniques, use acupuncture, are experts in manipulation techniques, have had success with neurostimulators to just name a few. My interventional radiologists use ablation techniques to treat phantom limb pain after amputations. Our insurance payers need to cover for these types of pain care. 4. Physical Therapists and Mental Health experts offer long-term and sustainable ways for movement and coping with other stressors that exacerbate pain. The greatest barriers are the lack of insurance coverage for these avenues of care and the common misperception that these are merely adjuncts and not medically sufficient for the pain. Refer your patients to a physical therapist or a counselor the next time they request opioids for chronic pain and see their response. Seek spiritual help because dependency or addiction are partly ways to replace unmet needs that the medical establishment do not address well. 5. Treat the cause, not just the pain. I am incensed when a patient with cholecystitis is sent home from the emergency room with an opioid medication when an antibiotic would serve more good. It might feel better to the patient in pain and a fast fix for hospital patient flow, but their problem is still brewing. Patients with fixable back pain should get the appropriate imaging and use all the non-surgical alternatives we know. Weight-related arthropathies are way too common and we should address these with what we do now. Helping patients lose weight makes definitive pain management easier. 6. It helps when a practice has a standard plan for pain management. It can be simple, or follow an algorithm. At the very least, a regimen for how prescriptions will be prescribed, when, and by whom, should be transparent for the team. This improves documentation (which is critical), would reduce any variations in prescribing patterns among all your staff and residents, as well as anyone who might inappropriately exploit prescribing gaps. Most importantly, a transparent policy would reduce mismatched expectations for pain management with our patients. 7. Educate our patients. A pill may seem the quicker option, particularly if one cannot do physical therapy or does not have access to some of the specialists mentioned above. But using multiple modalities is intended to reduce reliance on a singular “wonder” drug. Never assume that our patients cannot understand the complexities of pain management. Provide them with the same curriculum and resources as what we might want to teach our physicians. A patient who sees a pain management counselor or joins a support group should only be viewed positively. This is one editor's opinion, but no one I know takes opioids with the intention to become dependent or addicted, which also implies that these consequences arrive unannounced. Therefore, before taking drugs that have strong predilection for silently changing behavior, the patient should be given the opportunity to understand the root cause for their pain, and seek to treat the root cause using all the known options. Taking an opioid drug may temporarily mask your pain but the pain will come back and force you to take more.
I am not aware of the experiences our international colleagues have with opioid drug prescriptions. We would really like to hear from you about this problem.