PHARMACIST STEVE

https://www.painmedicinenews.com/Commentary/Article/03-18/What-Happened-to-the-Untreated-Chronic-Pain-Crisis-/47058

Simply stated, nothing has happened to the untreated chronic pain crisis. The same percentage of patients from the population still suffer from chronic, unrelenting pain. The only difference is this: We now know that one treatment option, when taken to the extreme, is not the simplistic solution that we had hoped for and were led to believe.

In retrospect, simplistic is a nice adjective along with delusional, foolish or academically corrupt to describe the belief that any human condition can be alleviated with a known addictive substance. How the pain management experts were able to dissociate from the accumulated knowledge of both medical experts and laypersons of the dangerous nature of opioids is beyond understanding.

During the 1920s, several laws were passed in the United States to deal with widespread addiction related to over-the-counter opioid availability. In the late 1960s, laws were once again passed to curb the overuse of various mind-altering drugs with the formation of a new drug enforcement agency. It appears that 50 years later, we made the same mistake again.

Addiction has been part of the human condition as long as recorded history. Addiction has even been used as a tool of war, for example, the use of opium by the British against the Chinese in the Opium Wars of the mid-1800s. There is growing consensus that the same percentage of the population has been addicted to some agents for at least several centuries. The overreliance on opioids for the treatment of chronic pain just substituted one psychoactive medication for others. It is interesting that as the opioid crisis has become more pronounced, there is less awareness of cocaine or methamphetamine addiction.

One new part of this equation is the development of a physician, pharmaceutical and insurance complex, with each achieving a different goal with opioid use but toward the same end. Now there is a massive rebound against the use of prescription opioids for chronic pain. In the process of righting the wrongs, a number of chronic pain patients who had regained function with the appropriate treatment of their disease state with opioids are now caught in the tidal wave and losing either their opioids or their function.

This loss of function has restored, in at least some of these patients, turning to street drugs, which have become ever more potent and dangerous. This is one unintended consequence of the appropriate reduction in the amount of prescription opioids written. All interested parties should now agree that the opioid genie is out of the bottle and can’t be eliminated from society. Well-intended prescribing guidelines and laws restricting the use of prescription opioids are inflicting real harm to patients everywhere.

The groups trying to alleviate this problem include lawmakers, who generally are poorly informed and trying to satisfy the needs of their constituents. There is a very loud constituency advocating for the reduction in addiction and overdose deaths. Lawmakers will attempt to pass laws that alleviate these problems, but inevitably, any law is so broadly written that it will cause harm to a patient whose chronic pain is being appropriately treated.

Pharmaceutical companies also have a very strong interest in the use of these opioid medications. Many new tamper-resistant opioids have been produced. Although many of these medications are more abuse deterrent, they are brand-name medications and generally poorly covered by insurance companies. The least expensive way to treat pain is with immediate-release opioids. These are also believed to be the most addictive medications. Because they can easily be either injected or vaporized and snorted, these medications have limited use in higher dosage forms. Insurance companies have also been reluctant to cover alternative treatments, such as physical and psychological therapies, for prolonged periods of time, which these patients need. Also, interventional techniques can help alleviate pain for at least a moderate amount of time.

One of the major problems with pain management, however, is that no technique has been shown to provide long-term pain control. Opioid medications; neuroadjunctive medications, such as gabapentin and dual-action antidepressants; traditional physical therapy, the above-mentioned procedures; and alternative treatments have not been proven to provide long-term pain control. The only techniques that have been shown to be helpful are some psychological techniques, such as cognitive-behavioral therapy. Therefore, it is difficult to advocate for any type of pain management treatment when, dependent on your point of view, nothing works. Further complicating the treatment of chronic pain are the comorbid conditions, such as psychological diagnoses, obesity, smoking, and social and societal problems.

This problem is in a state of great fluctuation. We’re at a point at which prescription drugs are being replaced by illegal drugs. This is further complicated by the fact that sophisticated pill presses can produce illegal pills that look like brand-name medications but can actually contain any number of psychoactive medications. The analogs of fentanyl are most dangerous; they can be up to 100,000 times as potent as opioids, milligram to milligram. The statistics are now likely to be corrupted because law enforcement members do not know what medications they are finding on overdosed patients, and only expensive toxicology reports can tell for sure.

The number of prescription medications actually peaked in 2012. However, the number of overdoses, overdose deaths and neonatal abstinence syndrome cases continues to grow. Emergency medical responders are actually becoming acquainted with addicts by name, as overdoses are becoming a recurrent emergency because of the prevalence of naloxone (Narcan, Adapt Pharma). Addicts can take themselves to the edge of death to achieve the most intense high, knowing that there is a good chance that they will be saved before they are not recoverable.

Because of the current fluctuation of the situation, the statistics that are being used are likely to be irrelevant to the current situation. One statistic that is assumed as fact is that more than a three-day prescription for pain medication will cause patients to become addicts. That is highly unlikely. A vast number of patients have been given post-op medications without becoming addicted. The treatment of chronic pain will require well-trained providers who are versed in a multidisciplinary approach, and a little bit of everything will be helpful.

Filed under: General Problems