The practice of medicine is a challenging yet rewarding field. On one hand physicians are sworn to do no harm, and on the other hand sometimes the medicines we use can lead to unintended effects that seem to do the opposite when not used as properly. One area of medicine that represents the promise and peril of helping while potentially causing harm is the practice of pain management.
A Unique Perspective
As a physician, I am in a somewhat unique class in that I prescribe both opioid pain management as well as opioid addiction medicine through my Data 2000 Waiver license to prescribe Buprenorphine in distinctly separate parts of my practice. This is a specialty combination that is not widely practiced by physicians in the US.
At first glance, this may even appear as a contradiction. After all, aren’t I prescribing the very drugs that people can potentially get addicted to and then providing the treatment for that condition? Doesn’t it seem to be an inherent conflict of interest?
So, let’s look at this legitimate line of questioning with another question:
Who would you rather have prescribing opioid pain management:
- A physician with little to no formal training in addiction or
- A pain management physician who also has specialized training and licensing to assess and treat addiction as well as a trained and experienced staff in the field of addiction?
The answer is not complicated. When it comes to pain management, there is no substitute for the specialized training, licensing and experience that comes from an addiction medicine physician and a trained and competent staff.
- This knowledge, training and experience helps create the safety margin designed to keep patients safe and helps to reduce the myriad of potential harms associated with opioid pain medications.
- This provides the framework that allows the physician and staff to offer the important types of education and support necessary for safe and effective pain management therapy.
Most Physicians Have Little Training in Addiction
Many doctors whether they are Primary Care Physicians, Surgeons, Emergency Care Doctors or other specialties who are licensed to prescribe opioids with little formal training in addiction are prescribing opioid prescriptions for patients and/or refilling them regularly on an ongoing or long-term basis. They do this because they do not want their patients to suffer.
From their practice perspective, pain management falls under their oath to do no harm. Their patients come to them with pain, and the solution according to their training is to prescribe drugs like Norco, Oxycodone and Percocet.
It is not uncommon for primary care physicians for example to simply continue to increase the dosage of short acting opioids like Norco, Percocet or Oxycodone when a patient continues to report increased or uncontrolled pain. Patients start at 3 Norco per day, then 5, then are prescribed to take two tablets up to 4 times per day as needed. Patients can become physically dependent on 2 or more opioid tablets per day and experience physical withdrawal when they stop the medication abruptly.
As we can see, without formal training in pain management or addiction, physicians in some cases are unwittingly creating a foundation not only of dependence but of possible addiction.
Dependency Vs Addiction
The most important thing to understand for physicians and patients is the very clear distinction between dependency and addiction.
Dependency is a Physical Diagnosis:
Many people are dependent on drugs for their daily function. If a person starts on an inhaled steroid to control their asthma, over time they will become dependent on that medication and will suffer withdrawal symptoms such as adrenal fatigue or increased inflammation in the lungs when they stop taking the medication. Over time, they may even need a stronger dose to achieve the same results. This does not mean that they are “addicted” to the drug. It simply means that their body has become tolerant to the drug and dependent on it for daily functioning. Ask any asthmatic, and they will tell you that most of the time this dependency is a worthy trade off.
When people take opioid pain medication, even if it is under the care of a doctor, their body can become physically dependent on the medication. This can take the form of acute withdrawal when the medicine is suddenly stopped or a need for larger doses to get the same analgesic effect over time as the body becomes tolerant to the drug(s). Simply put, the body becomes dependent on the drug, possibly even in slightly larger doses, for the same level of daily functioning that was provided at the initiation of therapy.
Addiction is a Psychological/Behavioral Diagnosis:
Addiction to a medication, much like an addiction to many forms of compulsive activity, is a psychological and behavioral diagnosis. A definition of addiction for opioids falls under a “use disorder” in the Diagnostic and Statistical Manual (DSM-V). There are several criteria that need to be met for opioid use to be considered a use disorder or what is commonly called an addiction.
Below are the criteria according to the DSM-V:
- An important thing to notice in these criteria is that a diminished effectiveness over time, need for larger doses for similar analgesic effect or physical withdrawal are not considered criteria for a use disorder when the person is under “appropriate medical supervision” and is not displaying any of the other criteria.
- In other words, physical dependency when an opioid is used as directed under the care of a physician is separate from a use disorder. This is the important distinction in diagnosing an opioid use disorder.
What I Look For In My Practice
Examples of the types of “Red Flags” that I look for as a physician include:
- Is the patient using more than prescribed or consistently running out of medication(s) before their next appointment?
- Are patients showing up with either none of their prescribed medication in their system or other opioid pain medications in their system that are not prescribed?
- Are patients consistently reporting their medication “stolen” or “lost”?
- Are patients consistently showing up for appointments with “new pain” or “new injuries” and asking for more medication because of this? For example, the patient is being treated for back pain while they await surgery, but they stubbed their toe and now need additional medication for “toe pain”.
- Are patients consistently asking for specific medications by name?
- Are patients showing drugs of abuse in their system such as heroin or cocaine?
- Are patients using all of their short acting pain medication for “break through pain” when they are also prescribed extended release opioids? If a patient is on long acting opioids they should need less short acting. If a patient consistently uses all medication prescribed no matter what, this is a huge Red Flag. Because of this we do mandatory pill counts at every appointment to monitor this.
- Are patients “doctor shopping” by seeing other doctors or emergency rooms to acquire additional pain medications? This one is so easy for my staff and I to track that I still can’t believe people think that this would work.
- Are patients displaying clinical signs of withdrawal during appointments such as:
- Running Nose/Tearing Eyes
- Gastrointestinal Upset
- Dilated or Pin-Point Eyes
- Increased Anxiety
- Heightened Pulse
- Visible Goosebumps on Arms
- Are patients consistently ignoring professional doctor/patient boundaries such as inappropriate attire, overly friendly and complimentary conversation or other behaviors especially when combined with any of the other things listed above?
- Has a patient recently been seen in local or state media such as newspapers or television related to a drug crime?
- Has a patient been reported by another patient or someone from the community as sharing their medications or selling them? This one is hearsay, but it mandates a follow up investigation on our part and should never be ignored or dismissed.
Like all areas of medicine, pain management has evolved. Historically, there were several ethical evolutions that took place. In order, these ethical steps looked like this:
1. Hospice Care – Use of opioids in the treatment of the terminally ill does not have the ethical considerations related to an outcome of addiction. This is comfort care pure and simple. This was the first area it was considered universally ethical in Western Medicine to use opioids for pain management.
2. Cancer Pain – Many forms of cancer produce profound pain for the patient. Even though opioids are not always completely effective for these types of pain, it later became ethically allowable to use opioids to treat this type of pain, and the benefits tended to outweigh the risks.
3. Chronic Non-Cancer Pain Conditions – In many ways, chronic non-cancer pain produces suffering and disability at least equal to that of cancer pain, but with higher prevalence and longer duration. Having to live with a broken back for example is a potential for a lifetime of pain. In 2010, the International Association for the Study of Pain (IASP) released the Declaration of Montreal which argued for “access to pain management without discrimination… on the basis of age, sex, gender, medical diagnosis, race or ethnicity, religion, culture, marital, civil or socioeconomic status, sexual orientation, and political or other opinion”. This was meant to distinguish the treatment of chronic pain from that of treating cancer related pain and included a declaration prohibiting discrimination based on “medical diagnosis”. This, along with the Relieving Pain in America position statement from the US Institute for Medicine, the foundation was laid for the treatment of long-term and chronic pain in the US and abroad as more or less a human right.
New drugs were being developed, and people rejoiced at the promise of relief for chronic pain that can affect as many as 1 in 4 Americans.
By now, the perils associated with opioid drugs has been very well documented. Hardly anyone in the United States is unaffected by the ongoing opioid crisis. Several key areas are worth noting here:
1. Rapid Escalation: Like many epidemics, opioid prescribing increased rapidly in the United States. The chart below shows the increase in opioid prescribing related to several factors:
2. Opioids Work on Not only Pain: It turns out that since opioids work on the endogenous opioid system which is a series of receptors throughout the body and brain, they actually affect many other functions besides the injury or illness induced pain for which they are most well-known.
Other Areas Affected by Endogenous Opioid System Are:
- maternal-infant bonding,
- reward associated with alcohol use,
- sexual reward and sex drive,
- mood regulation,
- social status,
- as well as eating, drinking, and other appetitive behaviors
The fact that opioids also work on systems that reduce stress has led many people to seek them for emotional relief and mood regulation. These are the main factors in the use disorders I see in my patients.
When a person uses opioids to numb emotional pain, they are at heightened risk for developing addictive behaviors and a full blown use disorder.
Similarly, when a person uses opioids to reduce the anxiety associated with social interactions, they can quickly become dependent on the drugs for socializing. When they are without the drugs, they run the risk of withdrawing and isolating or spending time finding the drugs instead of socializing. Once physical dependence exists and the rewarding feelings are no longer present, the person can end up focusing on the use for its own sake and end up withdrawn from social interactions that the drug used to help them with. This is a vicious circle that is perilous.
Addiction is the opposite of social integration and can lead to a repeating cycle of estrangement from important social contacts such as family, friends and community members as the addicted person spends an inordinate and dysfunctional amount of time in several key areas:
- Locating drugs
- Getting money for drugs
- Using drugs to the point of dysfunction
- Recovering from using drugs
- Criminal behavior and
Once a person consistently uses more opioids than are prescribed, uses non-prescribed opioids acquired from the street, forsakes important social connections in favor of the drugs, uses opioids for emotional management and continues to do so despite often severe negative consequences, then they have an addiction. They have found themselves caught up on the peril of pain management, and at that point they are often in need of professional assistance to overcome their use disorder.
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While opioid pain management holds the promise of relief from chronic pain, when used outside of the care of a trained medical professional with more than a passing understanding of how addiction works the promise can turn to peril before a patient or their doctor realizes it.
With the dramatic increase in prescribing of opioids for chronic pain in the United States, people with pre-existing risk factors such as social anxiety, historical or ongoing trauma or emotional/mental health disturbances are at heightened risk for developing a use disorder around these drugs when they are not under the care of a physician with proper training and experience. The fact that opioids work on a system in the body that is responsible for regulating so many of our important functions beyond pain, makes these drugs fraught with peril along with the promise of pain relief.
If you or someone you know has any of these risk factors or has developed a use disorder, seeking proper professional help from a board certified addictionologist or a substance recovery professional can be the difference between life and death.
National Library of Medicine – Opioid Therapy for Chronic Pain in the US
American Psychiatric Association – Opioid Use Disorder Diagnostic Criteria
Huffington Post – America On Opioids: The Many Faces Of The Country’s Addiction Crisis