Pain Medications – Seeking the Middle Way

If you’ve ever suffered from chronic pain, you probably have an opinion about pain medications. Years ago an illness drove me to the emergency room repeatedly for pain that was so bad I couldn’t think. Because my problem wasn’t easy to diagnose, the staff began to treat me as a “drug seeker”, someone who feigns illness in order to score pain medications. When I was finally admitted to the hospital the skepticism continued, with one doctor threatening to discontinue my pain meds altogether, saying I was becoming addicted. Some social work friends of mine finally threatened to bring a Medicare review against the hospital if I didn’t get what I needed – a consult with a pain specialist and the right combination of drugs. After this experience I’m always surprised at the number of private physicians who seem happy to pass out OxyContin and Vicodin like M&M’s. “Opioids,” according to the U.S. Food and Drug Administration (FDA), “are at the center of a major public health crisis of addiction, misuse, abuse, overdose and death.” Since physicians are prescribing the stuff it makes sense that possible solutions to the problem should come from physicians. As a favorite teacher once said to me, “You got yourself into this mess. You’re the one who has to get yourself out of it.”

Opioid medications consist of any of several synthetic compounds, such as methadone, which have effects similar to natural opium. The analgesic effects come from a decreased perception of and reaction to pain as well as increased pain tolerance; their popularity as recreational drugs comes from their ability to produce a feeling of euphoria. A study published in the British Medical Journal in August of this year supported a limited
need for opioid medications and noted that the number of deaths in the U.S. involving them grew from 4041 in 1999 to 14,459 in 2007. That’s more common than deaths from multiple myeloma, HIV and alcoholic liver disease.

When it comes to these deaths, at least two physicians have decided it’s time to do something. An oncologist in West Virginia, Dr. Hassan Amjad, and his colleague, Dr. Hassan Jafary, have formed the West Virginia Advocacy Group to help curb the problem of prescription opioid abuse by gaining refusals by other physicians to prescribe them. Through the advocacy group, volunteers circulate an agreement among area physicians. Line one of the agreement reads: “I do hereby pledge that no prescriptions for oxycodone will be written by me for any patient.” Dr. Amjad is asking other physicians to agree that, “Yes, we see the problem, we see young people dying. We will not write these medications.” Amjad believes that only patients with terminal illnesses, and not all of those, should take OxyContin or its various formulations and that physicians are not careful in prescribing them. He believes that giving them to patients with benign conditions such as arthritis or back pain is contributing to the drug problem in southern West Virginia. “There are patients who had foot surgery 10 years ago and are still getting these pills,” said Amjad. “Even as an oncologist, I am saying there is very little need for oxycodone and Percocet in treating patients. There is no way that a patient without a terminal illness needs these medications,” he told the Register-Herald, a West Virginia newspaper.

Sounds reasonable, right? Yet many believe that refusing the drugs to all except terminal cancer patients is a one-solution-fits-all approach with serious implications for patients with chronic pain. To them, describing arthritis and back pain as “benign” is not only ridiculous, but offensive. Both conditions can turn a person into an invalid, making the decision for a doctor to “never” prescribe them seem unreasonable. An argument can be made that a majority of the deaths involving opioids from 1999 to 2007 involved methadone and only a small percentage from oxycodone itself. In other words, drug addicts who receive methadone treatments for addiction and overdose from a combination of methadone with alcohol or other drugs drive up the statistics. Pain, according to Jeffrey Fundin, Associate Professor at the Albany college of Pharmacy, is the single most common reason for seeking medical care. Some 9% of American adults suffer from severe non-cancer pain. More than 50 million Americans are partly or totally disabled by pain, yet 40-50% of patients don’t receive adequate pain relief. Opioids, when used properly, are a very effective pain treatment, especially for people who can’t take non-steroidal anti-inflammatory drugs (NSAID’s) like Ibuprofen. While some doctors prescribe them inappropriately, others shy away from them for fear of patient addiction and side effects and their own disciplinary action or prosecution. Proper pain management is crucial, not only for chronic conditions but also for surgeries, injuries and the elderly. Dr. Amjad’s crusade to persuade doctors to stop prescribing opioids is like Prohibition in the twenties, when solving the country’s alcohol problem was going to be solved by taking it away from everyone.

Pain medicine is a specialty field – non-specialists tend to have limited knowledge on the subject. A neonatal intensive care nurse I know is always surprised at the narrow approach to pain management that physicians take on her unit. Their tendency is to fall back on a few drugs which tend to anesthetize the infants. Nurses find that multi-prong approaches to pain management are more effective, such as a combination of Tylenol, Versed (a benzodiazepine) and swaddling the baby tightly to make them feel secure. Physical therapy, chiropractic treatment and massage, nutritional supplements, biofeedback, acupuncture, stress management, exercise and diet have been found to be effective alternatives but many physicians are either ignorant of or hostile towards using mind-body therapies alone or as adjuncts to pain medications. Opioids are powerful weapons against pain but doctors have an entire arsenal they can choose from. When it comes to the subject of their use or misuse perhaps physicians should consider the middle way and moderate between the extremes of potentially dangerous, addictive chemical treatments and nothing at all.




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