I Hurt All Over

How to soothe the aches of chronic pain.

Opiate Medications: Pain Management Versus Addiction

Are doctors trained to recognize and treat addiction to pain medications?

Opiates, including medications such as morphine, oxycodone, hydrocodone, and fentanyl, are effective in controlling severe pain. They are often prescribed for short periods of time to treat acute pain such as that occurring after surgery or tooth extractions. These medications are also prescribed for a variety of chronic pain conditions. Unfortunately, although opiate medications are valuable tools for pain management, they are also highly addictive.

After taking opiates for extended periods of time, some people may find that they gradually need more medication in order to achieve pain relief (a process referred to as tolerance). This is a result of the physiological effects of opiates on the brain. Opiates gradually cause cellular, synaptic, and metabolic changes that diminish their effectiveness.  Additionally, as a result of longer-term exposure to opiates, different brain regions can begin to interact with each other and form new connections. This “rewiring” process can be the underlying pathway leading to addiction, and over time, a person may start to feel substantial anxiety and discomfort unless their brain is bathed in opiates. For some, the need to take more medication starts to dominate their lives. They may try to convince their doctors that they need higher doses of medication, or they may begin to visit several doctors in order to obtain prescriptions from each. Further complicating this scenario, longer-term opiate use often results in an abstinence (withdrawal) syndrome if these agents are discontinued abruptly. This is a highly unpleasant state with characteristic physical symptoms. The net result of all of these changes is a strong desire to continue opiate use even in the absence of ongoing pain.

Some individuals enjoy experimenting with opiates for recreational purposes. Increasingly, high school kids are doing this, and it is not unusual for teenagers to obtain these medications from their parents' medicine cabinets. Sometimes, young people begin to take opiate medications when they are prescribed to treat severe pain, for example, pain associated with a broken bone or wisdom teeth removal. Most are able to stop the medications after a few days. Some, however, enjoy the feeling the drug gives them and continue using the drug after the acute pain state is gone. They find ways to procure additional medication – perhaps from friends or by stealing from their parents. Some locate dealers who sell these pills. However, dealers charge a lot for prescription pain pills, and heroin, which is a powerful and highly addictive opiate, has become much less expensive than pills. Not only has heroin become affordable, the purity is such that it can be smoked instead of injected. Teens may be wary of needles, but smoking heroin may not be a big deal to them. Unfortunately, smoked heroin is extremely addictive, and teenagers are exhibiting increasing rates of heroin dependence. These teens sometimes find that heroin begins to control them and the need to obtain the drug dominates their lives, eliminating their common sense and judgment. Their lives dramatically change, and some make the leap to more powerful and dangerous intravenous heroin. This has resulted in an alarming increase in the number of heroin-related deaths among teens, an increase that cuts across socioeconomic groups.

These scenarios leading to addiction are often initiated by well-meaning doctors appropriately prescribing opiate medications for pain. Unfortunately, the doctors may not realize when an individual patient starts to develop an addiction. They may not know that their patient is receiving opiate prescriptions from other doctors. Why aren’t doctors more cautious about prescribing such medications? And why do doctors prescribe such medications even to persons they suspect might be addicted? This topic was recently discussed in an article published in the New England Journal of Medicine by Dr. Anna Lembke, a physician from the Department of Psychiatry at Stanford University.

Lembke suggests several reasons for doctors’ attitudes toward prescribing opiates. Physicians are strongly encouraged to help patients become pain free, and although physicians are trained in the use of opiates to alleviate pain, many receive little if any training in recognizing or managing addiction. Most medical schools simply do not provide sufficient training in this area. Lembke also points out that doctors are reimbursed for treating pain but are not reimbursed for diagnosing and treating addiction. Therefore, the medical reimbursement system reinforces opiate prescription but doesn’t reward steps to minimize the risks of addiction in patients with chronic pain.

Lembke also suggests that doctors are concerned that patients might rate them poorly on public websites if they are dissatisfied by a doctor’s refusal to prescribe “enough” opiates. This is becoming an increasingly important issue as physician reimbursement rates become linked to patient “satisfaction” ratings. There is also the possibility of public and legal censure against doctors who refuse to adequately treat pain.

Certainly, doctors could do more to correct a system that tends to reinforce overprescribing pain medications. Medical schools could provide better training in recognizing and treating addictions.  Financial incentives could be changed to encourage doctors to better understand, recognize, and treat addictions. Universal electronic medical records could also help to identify individuals who are obtaining opiates and other drugs from multiple medical sources.

As discussed in an earlier post, drug addictions are public health enemy number 1 in this country.  Addicting drugs include both legal drugs such as alcohol, nicotine, and opiate pain medications, and illegal drugs such as cocaine, heroin, and methamphetamine. How many destroyed lives will it take before the system is changed and common sense prevails?

 

This column was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD.