Make America Green Again: Opioids for Chronic Pain

Unless you have been living under a rock for the past few years, you are aware that there is an opioid epidemic.  Your 25-year-old cousin is now more likely to die from a drug overdose than from a car accident.  Much of this column is my opinion that has been derived from facts and 16 years’ experience as a physician working in primary care, the emergency department, and more recently in addiction medicine.

After my training in Columbus, Ohio, I began working in Redding.  Where I trained, opioids were infrequently prescribed for chronic pain.  In Redding, I was perplexed by the number of relatively young people who were receiving opioids regularly for chronic pain.  I would see people in their 40s who required 6 Norco (hydrocodone/acetaminophen) per day for their back pain.  At the same time, I would get x-rays of elderly patients in the emergency room whose spines looked like someone took a jackhammer to them and they would take a couple aspirin per day for their pain.

This never made sense to me.  Curious about this phenomenon, I have asked many older physicians over the past decade the same question, “Thirty years ago when we weren’t prescribing all of these opioids, were people’s quality of life worse?”  Nobody who has been in the medical field for decades has been able to honestly answer that we have made people better by the widespread use of opioids for chronic pain.

Part of the problem is the way that opioids work.  In the short term, they block the signals that your brain receives about pain.  If you break your arm and take some oxycodone, you will feel better.  However, if you take that same oxycodone several times per day every day, your brain changes.  It then takes more opioid to have the same effect.  Even worse, you go through withdrawal before each dose of medication.  A person’s brain then perceives this as an increase in pain and decrease in well-being.  Most people interpret this as a need to take opioids to control their pain and conclude that without these medications their pain would be severe and they would not feel well nor function in their daily lives.  In fact, for many people, it’s the opioid itself that is causing that pain and dysphoria (unease or dissatisfaction with life).  Opioids are known to cause a hyperalgesia, making normal stimuli turn into painful ones.  If you have ever seen someone in opioid withdrawal, they usually hurt all over.  In fact, I have seen many patients who have either taken themselves off the medication or were forced to stop.  Most were either no worse or much better than when they took the medication.  It is for this reason that people with chronic pain often find themselves taking escalating doses of medication and running out early.

There are many people who take opioids on a regular basis and don’t die.  So how do people who are not abusing the medications die from them?  One way is that our bodies develop tolerance to opioids and people increase their doses, sometimes to a level that is dangerous.  Many times, it is the addition of another sedating medication, like anti-anxiety drugs, or alcohol that worsens the sedation and respiratory depression.  In older people, these medications increase the risk of falls, which can lead to fractures and complications that result in death or disability.  Often, people drive while taking prescribed medication, not realizing that they are impaired (and that they can get a DUI), increasing their chances of crash.  This is something that I see commonly in the emergency department when patients are clearly quite impaired but they insist that the medication is not affecting them.  One risk that people who are on these medications often fail to appreciate is that they may do fine on medications for quite a while.  Then they get sick from a virus or pneumonia and that pushes them over the edge to over-sedation or not breathing, resulting in death or brain damage.  Their death may never get attributed to the medication that made them susceptible to this happening.

When the makers of OxyContin were marketing their new wonder drug for pain, they fed doctors the same bullshit study that only 4 in 10,000 taking opioids for chronic pain would get addicted.  This was from a letter to the editor that was published and was not based on good scientific data.  Nevertheless, physicians were encouraged to prescribe OxyContin, fentanyl patch, long acting morphine, and others for chronic pain while the drug companies emphasized how safe and effective the medications were.

To underscore the importance of treating all pain, all physicians in California were required by a law passed in 2001 to take a 12-hour course on pain management.  Thank you, lawmakers.  These courses emphasized the potential legal risks of undertreating pain as well as encouraging the use of opioids to treat subjective complaints of pain.  This is while the Joint Commission required the assessment of pain as the “fifth vital sign” and required the assessment of pain and evidence that the pain level was addressed.  As it turns out, a lot of people get addicted to opioids.  Addiction doesn’t just mean you have withdrawal if you stop taking it.  It is a psychological pattern of loss of control of use despite adverse consequences in your life, often despite a desire to stop using.  It’s difficult to get an exact number, but about 40 percent who take opioids for longer than 4 weeks are still taking them a year later, possibly a sign of addiction.  At least one out of six people who take opioids in the longer term meet criteria for addiction.

Here is how I think the discussion about prescribing opioids for chronic pain should go:  “I have a medication that will make you feel better when you take it for pain.  Although I am prescribing it as needed, you are always in pain, so you will probably take it regularly.  This medication helps in short term but probably makes your pain worse in the long term.  Since you will be relying this medication, you probably won’t focus as much on exercise and better ways to manage the pain.  This medication will impair your ability to drive and, although you tell me you won’t drive after you take it, you probably will, and it may cause you to get into an accident.  This medication may just kill you even if you take it as directed.  Although the chances that this helps you in the long term are relatively low, you may also become addicted.  This addiction may destroy all of your relationships, your career, and turn your life into a living hell.   You will then spend much of your time figuring out how to get more of the drug and doing things that you never would have imagined to obtain them.  Even though you say it will never happen to you, your addiction may take such a hold over your life that you turn to heroin.  At some point, you may find yourself unemployed, your family having given up on you, your children wanting nothing to do with you, your health failing, and you injecting heroin wondering how you could have possibly gotten there.  Do you want 30 or 60 pills?”

I believe it is a fallacy that any given patient can know if opioids will be safe for them and that any physician can predict who will benefit and who will have problems.  Certainly, we can detect those at higher risk (mood disorder, adverse childhood experiences, family history of addiction, personal history of addiction, etc.) but the no-risk population is a myth.  Time has proven that we harm more patients with opioids for chronic pain than benefit.  This is not the same for acute pain from conditions such as surgery, broken bones, etc.  This also doesn’t apply to end of life care where opioids are the mainstay of palliation of pain and suffering.  I am well aware that there are people who benefit from opioids for chronic pain and use the medications appropriately.  From a population standpoint, however, we have to look at the vast harm that they have caused and limit their use.

Much of the medical community has accepted that starting patients on opioids for chronic — not end-of-life pain — is probably not a good idea.  The hard part is what to do with those who are currently on the medications.  Two years ago, my answer would have been to leave people on the medication regimen that they are stable with and avoid opioids with benzodiazepines (sedative, anti-anxiety medications).  Now, I think that most people taking opioids for chronic pain should try to wean off of the medications over a period of several months.  The reason that I say that is more practical than medical.  At the beginning of this year, Attorney General and All Around Creepy Guy Sessions announced that he is stepping up the prosecution of physicians and pharmacies related to opioids.  There are indications that medical and pharmacy licenses will be revoked, and physicians will be prosecuted.  If your physician’s livelihood and possibly freedom is at stake for trying to treat your medical condition, they will change their practices.  Most providers will not take transfers of patients using chronic opioids for pain, so you have to hope that your doctor is in good health.

On April 2, the DEA sent out a press release that they had a surge in enforcement and administrative resources.  During this 45-day surge there were 28 arrests, 54 other enforcement actions, and 283 administrative actions (including revocation of DEA license).  This is just the beginning.  The message is clear that something has to change.

Although individual experiences vary, opioids for chronic pain cause more harm than benefit.  This is a problem that has been caused or at least worsened by the pharmaceutical companies.  Nevertheless, the medical community is changing its practices.  The government, through legislature and enforcement, is responding to the opioid epidemic through further regulation and enforcement.

If you have chronic pain, opioids are unlikely the answer for your long-term pain control.  Soon enough your provider’s hands will be tied because we have allowed the pharmaceutical companies to set this runaway train down the tracks that we haven’t been able to stop ourselves.

If you can, consider weaning off of the medications while the choice is still yours.  If you find yourself unable to control your use, there are resources in the community.  You can email me at gregagreenberg@icloud.com for resources or suggestions for opioid addiction.

Greg Greenberg
Greg Greenberg grew up in Santa Monica, California. After undergraduate training at UCLA he attended medical school at Ohio State University and completed a residency in family medicine in Columbus, Ohio. He moved to Redding after residency in 2004 and has served the Redding community as a family physician, hospitalist, emergency physician, and, most recently, in addiction medicine. When he’s not enjoying the calm atmosphere of the emergency department he enjoys the chaos of being a full-time parent as well.
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