The Beginning of the Opioid Epidemic

“What Happened?”

This was what my new IT consultant asked me regarding the prescription narcotic addiction epidemic that this country is currently being plagued by. He said he wanted to get the information directly from an expert. So here is a more historical, although still oversimplified, version of this complex issue.

Chronic pain is a medical problem that has existed for centuries. Soldiers in WWI were diagnosed with Complex Regional Pain Syndrome due to severe nerve injury, although it wasn’t named as such for decades later. Since the development of the Pain Management specialty in the early 1950’s, new ways of treating chronic pain have been adopted into the physician’s armamentarium. In the 1980’s, opioids or morphine like medications, i.e. narcotics, gained traction as legitimate and appropriate medications to treat chronic pain. The philosophy at that time and until relatively recently was, “give patients as much as they need to be comfortable”. Essentially what this meant was, if they continued to complain of pain, increase the dose. The risk of narcotic addiction was deemed “low” or less than 1% if the patient was being treated for a pain process. As a result, many people were helped and able to live more productive lives by the use of narcotic medications for severe pain.

Now, fast forward to 2003 when a national initiative occurred to treat pain as “the 5^th vital sign”. The four vital signs to assess someone’s wellbeing or acute medical state are 1.Temperature 2.Heart Rate 3.Blood Pressure 4.Respiratory Rate. As a new diagnostic tool, physicians were asked to evaluate and treat vital sign number 5: Pain Score. I believe that it is absolutely important to consider pain a vital sign for an acute situation such as for the postoperative assessment or acute injury scenario. In medicine, it is accepted that untreated acute pain can cause a multitude of complications including hypertension, hyperglycemia, anxiety, depression and chronic pain, to name a few. As a result of the initiative, which turned out to be largely funded by Big Pharma; who has patents on “designer” opioid medications; many physicians who weren’t previously prescribing pain medications began to do so in the effort to help more people.

Chronic pain is a very complicated process which is commonly confounded by factors that aren’t directly related to physical changes. Any kind of chronic pain can be worsened by depression, anxiety or any type of external stressor. For example, if a person with chronic low back pain is also undergoing a divorce or dealing with a death in the family, the severity of pain will seem much worse because their pain tolerance is lower. Emotional distress can make a preexisting pain feel more intense because one’s coping mechanisms are being overloaded and compromised by the additional burden. Narcotic pain medications should not be used in these circumstances and the dose for someone already taking them should not be increased to respond to this type of exacerbation. When narcotics are used to treat pain associated with a weakened coping mechanism, or “emotional pain”, the risk of long term use and addiction are greater. Also, there are other ways to treat pain besides medication such as nerve blocks, steroid injections, physical therapy, chiropractic treatments, biofeedback and relaxation, and acupuncture, that should be incorporated into both short and long term plans to avoid narcotic side effects.

Using a pain score to decide the amount of narcotic medication needed without also incorporating other assessment tools such as physical functional level, emotional state, mental function and overall health, can lead to over- prescribing, continuous dose escalation and an increased risk of overdose. Opioids also have what is called a “ceiling effect” which means that there is a limit to the pain relieving effect it can have despite how large the dose is. This is particularly important because there is no ceiling effect to the risk of overdose. The larger the dose, the more likely it is that a person can inadvertently overdose with it. Moreover, if a person is also taking a medication for anxiety and/or insomnia and/or drinking alcohol and/or taking illegal drugs, the risk of overdose then becomes exponentially higher because these factors all lower the threshold for overdose when combined with a narcotic medication.

I believe in order to restrain the prescription addiction epidemic, we all need to accept responsibility and act accordingly. Big Pharma should fund treatment centers for patients who have succumbed to addiction disorders to prescription opioids. Physicians who want to continue to prescribe opioids for chronic pain should have appropriate training or refer to those who do. Patients need to have realistic treatment goals and inform their doctors of factors that could increase their risk of addiction. Families of patients with chronic pain and or addiction need to get involved by providing additional support or information in the patient-physician treatment dynamic when needed. I appreciate it when family members accompany patients to office visits because it gives me another perspective on their home lives and functional levels that the patients don’t necessarily divulge.

My philosophy and approach to treating chronic pain is to balance the treatment modalities so that the patient has the benefit of different treatments that lower the risk of side effects to any one particular approach. I use medications to treat a specific diagnosis and cause of pain; which may or may not be opioid analgesics; along with steroid injections or nerve blocks that can break the cycle of pain and minimize the dose needed of pain medications. The goal of pain management is to reduce the suffering from pain and minimize disability in the safest possible way for the greatest benefit and least harm.