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Medicating Pain: Treating Patients, Preventing Abuse
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There has long been recognition in the U.S. that clinicians tend to under-treat serious, and especially chronic, pain. This problem tends to become most recognizable when the source of pain is objective, such as cancer, and when concerns about the consequences of pain medication use -- such as addiction -- are most questionable, if not downright silly.
When someone is likely to live for only a matter of months, for instance, the possibility of developing a dependence on narcotics is inconsequential, especially if it is the price to pay for a tolerable level of comfort. This concept has been fully embraced and best practiced by hospice, where the provision of comfort is the top priority. But there certainly are reasons for reticence about use of narcotic pain killers in general, even if those reasons unfortunately do spill over into areas where they do more harm than good.
Narcotics, like a number of other common drug classes, are "habit forming," meaning their use propagates their use -- and potential abuse. There are several elements to true addiction, the most notable of which being that whatever you needed the treatment for in the first place, you wind up needing it just because you need it; the dose for a constant effect tends to rise over time due to a phenomenon called "tolerance," and there is an unpleasant, if not overtly dangerous withdrawal syndrome if the "treatment" is stopped.
There are, of course, dangerous effects of such drugs unrelated to addiction as well. Narcotics and sedatives are both "mind altering," dulling mental clarity and potentially impairing judgment. Narcotics slow activity of the GI tract, causing constipation. More ominously, they can depress both blood pressure and respiration -- a potentially lethal effect.
Coupled with these harms is the unfortunate experience every doctor-in-training has with so-called "drug seekers." One of the more common ploys used by addicts to get narcotics is to go from ER to ER, shift to shift, with a different story each time about a severe pain for which only narcotics will do.
Working sequential day and night shifts in an ER some years ago, I encountered the same drug-seeking patient who, not remembering me (those "dulling mental clarity" effects, presumably), used totally different stories in the span of 12 hours to justify a narcotic prescription. This was one of the rare cases where any doubts I had about a scam versus real pain were fully resolved.
Since it looks bad on a doc's resume to be giving out narcotics just because somebody wants them, we learn -- for better or worse -- to be suspicious, and cautious. But there is an inevitable trade off: the better we are at keeping narcotics out of the hands of those who, in principle, shouldn't be getting them, the more we risk denying them to those who certainly should.
And now, the plot thickens with a recent report generated by the Centers for Disease Control and Prevention, and the Substance Abuse and Mental Health Services Administration showing that the number of emergency department (ED) visits involving non-medical use of prescription opioids increased 111 percent during the most recent five-year period. As of 2008, annual emergency department presentations for misuse of sedative and narcotic drugs combined, mostly by adolescents and young adults as one would expect, greatly exceeded 500,000. During this same period, emergency visits related to illicit drugs were fairly stable.
So we find ourselves between the proverbial rock and hard place. We often fail to treat chronic pain adequately, yet the very drugs we prescribe to relieve pain wind up causing it -- not to mention the threat of death -- in others. What's the answer?
I can't say that I have one; it doesn't seem that anyone does. But I do have ideas, and it's clear we need to do something.
For one thing, physicians prescribing these drugs need to let their patients know about the potential for abuse. Narcotics and benzodiazepine sedatives (i.e., drugs in the same class as Valium) in the home are a bit like a gun in the home; used in the wrong way by the wrong people, they are lethal. They should be kept safely locked out of the reach of anyone for whom they weren't specifically intended.
Parental awareness, and vigilance, are essential. Parents of teens and young adults need to know the magnitude of this problem, and the booming black market for pilfered prescriptions. Forewarned is forearmed.
Educational programs for the young that have traditionally focused on the hazards of illicit drugs, such as DARE, need to keep up with the times. Prescription abuse seems to deserve equal coverage now. Ideally, a more realistic sense of the danger of these drugs might dissuade at least some young people from putting them to recreational use. Working against this, I suspect, is the notion that if something is 'legal' it must be safer than something that isn't. Alas, this is utterly untrue; a synthesized narcotic considerably more potent than heroin is perfectly legal by prescription, for example.
The most fundamental solution -- the solution most fraught with both promise, and peril, in my view - is to have fewer of these drugs in circulation to begin with. The promise is obvious: if there were fewer prescriptions for pain killers and sedatives, there would be fewer opportunities for the abuse of these drugs. Fewer people would ever encounter them.
The peril, though, is that people in pain would be denied needed treatment, and that is not my intent. Rather, we can, and should, do a better job of treating such needs in other ways.
Pain can often be treated with physical therapy, massage, biofeedback and so on. Colleagues and I, for instance, published a study of massage therapy for osteoarthritis of the knee, showing remarkably good and persistent effects; we are currently completing a follow-up study.
Pain often subsides considerably just by improving sleep, which is often deficient, generally neglected in clinical encounters, and usually fixable when addressed. Anxiety can be treated with mind-body techniques. But these interventions take more time and effort than a reflexive prescription. The always rushed, on-the-fly system of health care we have cultivated tends to favor, and foster, the expedient approach. But if a little more time for thoughtful approaches to pain management means, among other things, fewer overdoses to treat in the Emergency Department, I would hope all concerned could agree it is time well spent.
Drugs prescribed to alleviate pain represent good intentions; but they are subject to the unintended consequences of bad use. It may seem as if we are damned if we do dispense drugs to treat pain, and damned if we don't. But we should be able to implement an array of strategies in which we all have a role to play -- among them better use of alternatives to knee-jerk pharmacotherapy -- so that prescription pads reliably do more good than harm.
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