by frankieleon/ via flickr
Many patients and clinicians have strong feelings about opioids: they’ve seen a loved one denied adequate pain control, or they’ve seen a family member or friend’s son or daughter lost to prescription pill and/or heroin addiction, or they’ve worked in an ED with too many drug-seeking patients, or they’ve seen a patient in terrible pain waiting for a new analgesic order from an unavailable or uncompassionate physician.
But feelings don’t solve complex problems, and an excessively punitive or permissive approach can do more damage than good. Recently, there have been almost daily headlines and policy recommendations about the importance of restricting opioid-prescribing practices. The trend is alarming a number of clinicians with expertise in working with patients in pain. Clinical nurse specialist and pain management consultant Carol Curtiss addresses what’s at stake in “I’m Worried About People in Pain,” the Viewpoint essay in the January issue of AJN:
According to a 2011 Institute of Medicine report, chronic pain is a public health crisis . . . Well-intended efforts to address prescription drug abuse—another public health crisis—may place heavy burdens on people with pain who benefit from opioids and use them responsibly as part of a comprehensive treatment plan. . . . Gains made in pain treatment are at risk. New regulations threaten access to opioids for people with pain.
The essay details other unintended consequences resulting from a host of new or proposed regulations about opioid prescribing, including stigmatization of patients at times when they are most vulnerable and unrealistic regulatory burdens on clinicians, leading some to avoid prescribing opioids even when they are clearly indicated.
No ‘quick fix.’ No one denies that a subset of patients use prescription opioids inappropriately, or that a subset of clinicians and clinics in certain states prescribed for personal gain or in a spirit of recklessness. According to Curtiss, there’s much that can be done or is already being done to mitigate such concerns:
Controlling prescription drug abuse is critical, as is improved access to mental health and addiction treatments. But there is no “quick fix” for these complex problems. State prescription drug monitoring programs must collaborate to make databases available to clinicians across state lines. Prior authorization processes must be more efficient and more transparent. Clinicians should follow current guidelines that recommend comprehensive assessment and ongoing screening before and during opioid therapy; initiating opioids after risk–benefit analysis and as part of an individualized plan; measurable treatment goals, etc. . . .
But, says Curtiss, “denying or making access to pain medications more difficult for people with pain is not the solution.”
Curtiss reminds nurses that “
Not all pain problems are fixable. I have CRPS/RSD and intractable neurological pain disorder. The pain nearly killed me. I dropped down to 119 pounds from a healthy 130 during my endless search for a diagnosis in Houston all the while being accused of being a drug seeker. The pain was so bad if someone touched my arm it felt like a dentist hitting the raw nerve in the tooth with no Novocaine. I can’t live without opiates, and this notion of putting more and more burdens on legit pain management doctors hurts legitimate pain patients like me. I became suicidal from the pain until I finally got a diagnosis from a neurosurgeon who then sent me to a pain clinic. I’ve done it all: physical therapy, spinal cord stim, pain patches, nerve blocks. I need opiates to live. The minute I cut back on my very low dose the monster comes out of the box. People need to get it that some pain can’t be fixed and nerve pain is the absolute worst. Try walking around with the worst tooth ache of your life for a year like I did and then come back to me and talk to me about how we need to fix the problem. Some physical diseases like CRPS/RSD can’t be fixed and to think so is naive.
If it was only that easy … I think you are reaching when you state that oral opioid pain killers inevitably lead to heroin. That is simply not true. There will ALWAYS be ailments that cause pain. If we had a cure for cancer, or nonsurgical means to fix fractures or what not, we would be miles a head of the pain game for sure. There are other pathways in the brain available to block pain – we need more research into non opioid treatment for pain. In the meantime, they are all we got.
The problem lies with the way opiate medications are managed for pain control. The minute a patient with chronic pain starts opiate pain medication therapy, their brain is altered. Their brain begins to “forget” how to process pain correctly. When the opiates are brought in they lessen the brains overall ability to tolerate pain of any kind without needing that opiate for “protection” from pain any longer. Doctors forget this. There needs to be focus for curing the reason for the pain rather than long term pain management with opiate medications. Opiate medication dependence leads to increased tolerance almost 100% of the time. Opiate painkillers scripts taken away from pain patients suddenly leads to purchase off the streets, which then leads to dealers saying ‘Hey I don’t have anymore Oxy, but I’ve got this heroin – it’s cheaper and ever better’ then it’s off to the races. I see it every single day where I work. EVERY DAY. This isn’t about prohibiting patients with chronic pain from getting managed pain medications… it’s about protecting them from the inevitable if the reason for their pain isn’t ever fixed properly – which it should be!