PAIN MEDICINE MAYHEM

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One does not need to listen to the news very long to realize there is a problem in the United States with people overdosing on controlled substances.   More than 16,000 die every year of prescription drug overdose .  This is more than die annually in motor vehicle accidents.  In addition to overdose deaths, there is also significant other mayhem being caused by controlled substances.  There is no question prescription controlled substances are a major problem in this country.  How did we get here?

Substance abuse has been a problem for all of human history.  The thing that has changed in recent years is the amount that prescription medicines are now one of the major components of the illicit drug scene.  Prescription Controlled substances include narcotic pain medicines  (Lortab, Norco, OxyContin, etc.), benzodiazepines for anxiety (Valium, Xanax, Ativan, Klonopin, etc) and ADHD meds (Ritalin, Concerta, Adderall, Vyvanse, etc.).

In the 1990’s  there was increasing activism that doctors were not adequately treating pain.   As a result, in 2001 “pain” was officially established as the ‘5th vital sign”. Now, not only were medical personnel expected to treat pain more aggressively, but they were mandated to eliminate patient’s pain.  This happened at the same time as options for treating patient’s pain, such as Darvocet and Vioxx were taken off the market.  More recently the use of ibuprofen, Tylenol and codeine have been discouraged.  The result was that the amount of strong narcotic pain medicine prescribed increased dramatically.  For a short period of time, things were good.  Patients felt like their pain was being addressed and treated.  Regulators had something else to measure and with which to cite health care providers.  Physicians felt more comfortable treating pain more aggressively. More potent, long acting pain medicines were subsequently developed, to meet this new need.

Then the inevitable negative consequences of government mandates started occurring.  Stress levels on nursing increased as they tried to meet the unrealistic regulatory requirements. The addictive nature of narcotics (that were ignored in the push to more aggressively treat pain) became increasingly evident.  It started to be realized how short a time it took to become physically and emotionally addicted to these substances.  It was realized that it took an ever increasing amount of medication to provide the same amount of pain relief.

As the number of patients using narcotic pain medicine increased,  prescription medicines started being diverted into the illicit drug use culture.  Even legitimate pain patients began engaging in manipulative behavior in order to obtain adequate pain relief.  Unfortunately, the number of overdoses also began increasing.

When deaths from prescription medications increased, regulators, politicians and organized medicine decided it was their job to fix this problem.  They never admitted, they were the cause of the problem.  Instead, they blamed the doctors prescribing the medicines. They never acknowledged that all of these deaths occurred not when the medications were used as prescribed, but rather when they were misused by the individuals using the medicine.    They argued doctors were prescribing without adequate education on the use of controlled substances. They blamed greedy pharmaceutical companies for developing medications to meet the need the regulators had created.  When patients misused pain medicines or took them in inappropriate settings or diverted them, the doctor was blamed, rather than the patient taking the wrong action.

It was decided the way to fix this problem was to require more documentation and regulation. The various agencies issued “guidelines” that significantly restricted the prescribing of pain medicine.   The enforcement arms of government started raiding doctors offices and auditing charts.  Many physicians, especially solo physicians, were removed from practice.  Various regulations have made the actual prescribing of all medicine, especially pain medicine, more difficult and inconvenient.

Physicians are now required to do yearly education on the treatment of pain.  While learning what is currently known about pain mechanisms and the treatment of pain is helpful, so much of this education is totally disconnected from real everyday practice.  It pretends there is a way to distinguish between legitimate and illegitimate seekers of pain medicine.  It continues the fallacy that the pain medicine problem was caused by physicians and they can control patient’s behavior.  It still promotes the fantasy that it is possible to objectively quantify the totally subjective symptom of pain.  It tells us acute pain only lasts 4-5 days and after this patients no longer need narcotic pain medicine.   It tells us chronic pain should be managed with counseling and physical therapy, instead of narcotics. Then it gives no answers to what we are supposed to do when these modalities do not work or, as in many cases, are not available.  .

These pain education courses never tell us practicing physicians what we are supposed to do with the patient we are sitting with, who is crying and begging for relief from their pain.  What are we to do when we are cursed and threatened because we refuse to treat a patient’s pain.  These courses never acknowledge that every single human being wants relief when they are in pain and that relief of suffering used to be a primary role for physicians.

The results of these efforts to fix this problem from the top down have not been positive.  What has not happened is a reduction in overdose deaths.  Heroin use has gone up as  prescription medications have become less available.  The use of Suboxone is being promoted, which is an insanity.  Suboxone is just an expensive form of the travesty of methadone clinics.  People  in chronic pain are becoming increasingly desperate and deliberate suicides are increasing among them.  Even people with acute pain needs are no longer being given adequate pain relief.

We have gone from a state where the treatment of pain may not have been perfect, but for most it was adequate, to a state where pain medicines were way over prescribed.  Now those same entities that promoted the overprescribing,  have swung the pendulum totally the other way.  I tell patients that the government has declared there is no such thing as chronic pain.  While this is technically not true, in practical terms it is the truth.  Physicians have become afraid to prescribe pain medicine.  Those with chronic pain can find no doctor, not even pain management physicians to treat their pain with medication.  Even for surgery or significant injuries, frequently patients are given inadequate amounts of pain medication, thus increasing the burden of suffering on everyone.

Politicians and regulators have all looked at the overdose problem and concluded that it is the doctors fault we have this problem and it is now the politicians and regulators job to fix this problem.  I contend that politicians and regulators are the ones who created this problem and in the usual fashion of public policy, their response will not fix the problem of drug addiction and overdose, but it will have many casualties in the attempt. Those casualties will include every one of us.

 

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