Opiates and Pain Management: Pandora’s Box
Today is National Overdose Awareness Day and an appropriate time to discuss the terrible epidemic of opiate addiction that we are seeing, not only in our community, but nationally as well. The statistics are staggering as according to SAMHSA (Substance Abuse and Mental Health Services Administration) there were 1.9 million prescription opiate addicts and another 600,000 or more heroin addicts in 2009 and the numbers are increasing. Accidental overdose has overtaken car accidents as the number one killer of young people 18 to 44 who are not only in their prime of life, but also the primary producers in our economy and society. It is estimated that overall, 24 million people in the US have an addiction and only about 1-2% are receiving treatment for their addiction.
I could easily write an entire paper on the staggering cost of addiction, not only in loss of human lives but also in economic costs to this country; however this paper is about the people affected by this horrible epidemic and not about statistics. There have been a number of stories and citizen comments recently in our news and newspapers about young people tragically dying of heroin overdose and doctors over-prescribing narcotic medication. This paper is written to try to bring some insight to the community of the scope of this problem, how we got there, and some possible solutions.
Sometime in the middle of the last decade, several national and international organizations, including the WHO (World Health Organization) drafted and adopted a Patient’s Bill of Rights that dealt specifically with pain management. Specifically and amongst other things, it stated that all patients “have a right to proper, respectful, informed, and non-discriminatory pain management and care”. Prior to this shift change in medicine, opiates had more or less been reserved to manage chronic pain only for patients with advanced cancers or other end-stage painful conditions. Apart from these patients, the only other use for opiates was generally for the short term treatment of severe acute pain postoperatively or for severe acute trauma. Following the lead of the national and international organizations, most state medical boards and societies adopted the Pain Patient’s Bill of Rights and Pandora’s Box was opened.
Since then, millions of patients have been treated and are being treated with opiate pain medication for a variety of conditions including headaches, chronic back pain, arthritis, fibromyalgia, and just about any other disorder that causes pain. While the overwhelming majority of these patients are being treated for legitimate pain by well-meaning, well trained, and legitimate physicians and are not abusing their medication or addicted, many of them do become addicted and/or dependent and a few obtain their medication illegitimately, by ruse or illegally. Unfortunately, there have been—and remain--more than a few unscrupulous and unethical doctors who have been more than happy to provide some of the latter “patients” with prescriptions for narcotic medication.
The opening of Pandora’s Box has produced a schizophrenic medical community with doctors under pressure to respect and adhere to the “Patient Bill of Rights” by providing legitimate patients with adequate and compassionate pain management on the one hand while feeling threatened or intimidated by the DEA and other law enforcement agencies if they chose to treat such patients. Another problem arises when all physicians know and understand that while the majority (more than 80%) of patients treated with opiate pain management will never develop an abuse problem or addiction, about 10% will ultimately develop an addiction with its attendant negative consequences—including risk of accidental overdose-- on those patient’s lives. Unfortunately for us, patients do not carry a sign with them that warn us that a particular patient will become addicted. Furthermore, since pain is a subjective and individual experience and is modified by emotional, physical, and psychological states, it is impossible for any physician to be 100% certain 100% of the time, who is legitimately seeking pain management and who is not.
By some of the reports in the news as well as some of the citizen’s comments, it would appear that there is a perception that most physicians are just “willy nilly” handing out prescriptions for opiates to just anyone who requests them without consideration of the consequences. As I have mentioned earlier and which have been documented in news stories across the country, I acknowledge that there are unethical and unscrupulous physicians who are prescribing for profit, but like the minority of legitimate patients who become addicted and cause problems to themselves and society, they are in the vast minority! In fact, statistics from SAMHSA indicate that in most communities, most “illegitimate” prescriptions are coming from only 1 or 2 doctors. Most doctors take their responsibility to their profession and society seriously and understand the risks of prescribing opiate medication. We also understand that the majority of people prescribed such medication will also be responsible and never develop a problem with it and we are constantly weighing the risks versus the benefits of prescribing such medication to each and every patient. It is inevitable that some of us will be duped by some “patients” and it is also inevitable that some legitimate patients will develop an addiction and that is the risk we take while Pandora’s Box is open.
Another common misperception is that many teenagers and young people are becoming addicted to opiates obtained from doctors. There are very few indications to treat a young person with opiate medication and most physicians are hesitant to prescribe these medications to teens and young people except in cases of moderate to severe pain from orthopedic or operative trauma. Statistics from SAMSHA and from my personal experience as an addiction specialist, most teens and young people (55%) report that they are getting their opiates right from home (friends or family), 17% report getting them from one doctor, and the rest from the street. Of those that reported obtaining their medication from friends or family, 80% of the friends or family members reported getting their medication from only one doctor.
So what can we do about Pandora’s Box? According to legend, once it was open, there was no way of closing it and I do not believe that there is any way of closing our modern day version of the box. However, the one thing that remained in the box was hope and it with hope that we can possibly change things at a variety of levels including personally, professionally, and legislatively to effect positive change in our communities and society at large to combat this insidious and horrible epidemic that is claiming the lives of our youngest and most productive individuals. Every time one of our young people dies from an overdose, it robs us all and our society of a “what if”—what if that person was going to be the next doctor to cure cancer or addiction, a great actress or actor, singer or athlete, or the next CEO of a great company, or even the next President.
While I do not profess to have all of the answers to this complex and vexing problem, I do have some suggestions, some of which will undoubtedly bring much scorn and criticism upon me from colleagues and others. I will outline these suggestions from a personal to professional to a legislative order.
Personally, as individuals we must all become aware of this insidious epidemic and must educate ourselves—and our children-- about the risks and dangers of opiate addiction when given these medications, even for short term use. As parents, we must educate ourselves to the signs and symptoms of addiction so that we may intervene early and decisively should we suspect our children or loved ones of developing a problem or experimenting with opiates. If we are obtaining and using opiate medication we must take measures to safeguard our medication and keep them out of the reach of children and inquiring minds. We can become advocates in our schools and our communities, becoming involved in groups and organizations, such as the Heroin Action Committee, that spread the word about this problem. Lastly, we must learn and understand that addiction is a disease and should be treated like a disease without the stigmatization that surrounds it and which stands as a barrier to many of those who would otherwise seek treatment.
At a professional level, we must take our heads out of the sand and acknowledge the epidemic of opiate addiction that the opening of Pandora’s Box has caused. We must keep up to date on the standards of care for the treatment of chronic pain and we must also keep up to date on the advances that are being made in the non-opiate management of chronic pain as well as the advancements being made in addiction medicine. We too, must divest ourselves of the cloaks of superiority and ignorance and recognize addiction for the disease that it is and not the old stereotypes we might still believe. We must accept our part in this epidemic and be more diligent about truly doing risk analysis every single time we write a narcotic prescription, including opiates, benzodiazepines, and medication for ADD. We must recognize our educational and training limitations and refer those patients requiring complex psychological and concomitant pain management to appropriate specialists. It is our house where Pandora’s Box came from and we must clean our house or others will clean it for us and ultimately, the patients and society will suffer.
At a legislative level, which must occur at both the state and federal levels, there are several things that can be done. First of all, hydrocodone and tramadol should be made scheduled II narcotics and all scheduled II narcotics should be controlled and prescribed only by appropriate specialists or physicians who have demonstrated interest, experience, and proficiency through conferences, courses, and continuing medical education in pain management—as well as addiction-- to their respective state medical boards or licensing agencies. It is interesting that I must demonstrate proficiency to apply for a license to prescribe Suboxone which treats addiction, but I have no restrictions whatsoever to write for all the drugs that cause addiction! For those specialists that may often treat acute severe pain, such as surgeons, orthopedic surgeons, or ER/Urgent Care physicians, strict limits should be made with respect to amounts written for and duration of treatment for all scheduled II drugs. All states should be mandated to have a reporting mechanism through the pharmacy boards where all physicians should be mandated to access and report to before prescribing scheduled II medication. On a broader level, we must enact legislation that shifts the emphasis from punishment to prevention and treatment for those that struggle with addiction. We should encourage and expand dramatically the number of doctors and midlevel providers who wish to provide outpatient opiate addiction treatment with Suboxone. As a society, we too must understand that addiction is a neurobiological disease manifested by abnormal behavior, not abnormal people voluntarily engaging in harmful and bad behavior!
Pandora’s Box may be open, but by coming together as citizens, professionals, and policy makers, we can perhaps reopen the box and bring hope to our communities and to society.
John R. Vigil, MD