doctors aren’t prescribing opioids like they used to, and what those of you struggling with chronic pain can do about it

WONDERING ABOUT THE OPIOID CRISIS?
HOW TO ADDRESS YOUR CHRONIC PAIN WITHOUT NARCOTICS

Opioid Epidemic

“Wish I didn’t know now what I didn’t know then.”  Bob Seger and the Silver Bullet Band, from 1980’s Against the Wind
I have been known to take the medical community to task for the ridiculous ways they often treat their patients — frequently using methods that run exactly opposite of what the peer-reviewed research indicates is best (HERE is a great example of this).  It’s why I have said time and time again that the gap between medical research and medical practice is in many arenas, wider than the Grand Canyon (HERE).  Today, we are going to talk about the “Drug Crisis” here in America, what’s being done about it, and how doctors — while the most obvious scapegoats — are not completely to blame for everything you’re hearing in the news.   You probably won’t be surprised to learn that like any number of similar problems (HERE is a biggie) our government is largely at fault for this one as well.

This fiasco reminds me of the sub-prime lending crisis of a decade ago.  Thanks to cheap credit, more people than ever could afford the American Dream — owning their own home.  Because lawmakers wanted even more people — even those with poor credit scores — to be able to afford their very own home; already loose credit was loosened even more.  Banks were told to lend, lend, lend.  Damn the torpedoes, full speed ahead!  As credit got easier and easier to get, demand soared, prices skyrocketed, people invested fortunes in real estate, and all was well with the world.  Until the bubble burst.  The result was millions of Americans upside down in their mortgages, with a large percentage of these individuals losing their homes.  We can blame the banks all we want, but for the most part, they were only doing what lawmakers and regulatory agencies told them to do.  Follow along as I show you that the same thing is true of the Opioid Epidemic as well.

Pain has always been something that people seek out their doctors for.  But as far as the way doctors treat pain; everything began to change back in the late 1980’s and early 1990’s.   Because of this change, doctors ended up caught in a sort of Catch-22 — a damned-if-I-do, damned-if-I-don’t situation as far treating their patient’s pain is concerned.  The October 28, 2013 of Physicians Weekly (Is Pain Really The 5th Vital Sign?) captures the essence of this dilemma.  The author of their blog (an MD who goes by Skeptical Scalpel) complains that…..

“Doctors are caught in the middle. If we don’t alleviate pain, we are criticized. If we believe what patients tell us—that they are having uncontrolled severe pain—and we prescribe opioids, we can be sanctioned by a state medical board or even arrested and tried.”

What the author is saying is true.  I started Chiropractic College back in 1988, graduating in December of 1991.  Although helping patients with pain has always been a chief thrust of what I do (HENCE, THE NAME OF MY FIRST WEBSITE), there was not the huge emphasis on pain diagrams or the “1-10” pain-scale charts that today are virtually ubiquitous in physician’s offices.  But not long after starting my practice, word came down from above that pain had become the single most important metric to chart. Thanks to concurrent campaigns by well-meaning physicians and money-hungry pharmaceutical companies (you’ll soon see that some of these physicians’ motives were not as altruistic as they led everyone to believe), pain became the, “Fifth Vital Sign”.  Here are a few sentences taken from something published back in the early 1990’s (Make Pain a Fifth Vital Sign)…..

“Making pain a fifth vital sign is a relatively straightforward way to improve pain management. The American Pain Society first promoted the phrase as a way to increase awareness of pain treatment. Simply by requiring routine pain assessment – along with pulse, blood pressure, respirations, and heart rate – organizations make pain management a priority.   Teams that try this approach need to simultaneously develop (or use) protocols for managing any pain intensity level greater than 3 (on a 0-to-10 scale).”

The four classic Vital Signs are all easily and objectively measured.  Unfortunately, pain is not.  Humans don’t come with a little black box that we can interface with our computer to see just how severe a patient’s pain really is.   The subjectivity of pain is what makes it so different from the other Vital Signs.  For instance, I routinely have patients who use their “accident” insurance policies, which requires them to fill out a little how-did-you-injure-yourself form that has a built-in pain scale.  It is not uncommon to see walking, talking, thinking, smiling, laughing patients mark their pain as an 8 or 9 out of 10.  On his blog Status Iatrogenicus (Pain Is The Fifth Vital Sign – And If You Don’t Have Any, You Might Be Almost Dead) Dr. Scott Aberegg addresses this all too common phenomenon. 

10 out of 10 pain is when a civil war barber cuts off your unanesthetized leg with a carpenter’s saw (a bullet to chew on and a shot of whiskey to take the edge off supplied as a contemporaneous courtesy).  That’s 10 out of 10.

On the flip side of this coin are the minimizers (there are more of them out there than you would think). ‘Minimizers’ is the name I coined for those people who never let on how bad things really are.  They are sort of like the “Black Knight” from Monty Python’s Holy Grail.  They might end up losing every appendage, but would never for one second let on to anyone other than maybe a spouse that it hurts (HERE).  Many men — particularly of the GREATEST GENERATION — grew up with this mindset.  The truth is, both approaches to dealing with pain are problematic.  Again, from chapter 3.8 of Improving Care for the End of Life (Make Pain a Fifth Vital Sign)…..

“Implementation of `Pain as the Fifth Vital Sign’ is a mechanism for identifying unrelieved pain. Screening for pain can be administered quickly for most patients on a routine basis. As with any other vital sign, a positive pain score should trigger further assessment of the pain, prompt intervention, and follow-up evaluation of the pain and the effectiveness of treatment.”

The problem is (as we noted a few paragraphs ago) that the medical ‘Standards of Care’ dictate that doctors need to be managing pain for anyone with a 3 out of 10 or greater.  The question always arises; how are doctors to know which group is which?  Who are the drug seekers, and who are the legitimately suffering?  Sometimes it can be tough to differentiate because there can be overlap between the two groups.  Because of the recent focus on the “Opiod Epidemic,” this problem is getting worse.  Not only have I seen it in here, but one of the journals I get (PRACTICAL PAIN MANAGEMENT) has revealed that due to fear, doctors are increasingly viewing everyone as a drug-seeker (unless you have an injury like the Black Knight above).  Threats of fines, jail time, and / or license revocation, is more than enough to keep the pens and prescription pads in doctor’s pockets.

I would argue, however, that none of this is really addressing the bigger question.  Does our current stated policy of treating anyone with pain over a “3” work?  The clear and obvious answer is no, it doesn’t.  Allow me to turn to the peer-reviewed literature — but with a caveat; that WE CAN’T REALLY TRUST IT.  Besides the link I just provided you, allow me to show you what I mean concerning this issue of pain management.

Four years ago, the Wall Street Journal carried an article (A Pain-Drug Champion Has Second Thoughts) about the pain specialist widely considered to be the father of the current practices concerning “Pain Management” — Dr. Russell Portenoy (a past President of the American Pain Foundation).  “It has been his life’s work.  But now, Russell Portenoy appears to be having second thoughts.  Now, Dr. Portenoy and other pain doctors who promoted the drugs say they erred by overstating the drugs’ benefits and glossing over the risks.  ‘Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did,’ Dr. Portenoy said in an interview with The Wall Street Journal.  We didn’t know then what we know now.‘”

Dr. Portenoy based his concept for prescribing opiods to anyone with even low-grade pain, on a study that essentially said this class of drug was only problematic (addictive) for 1% of the population.  It came from research published in a thirty year old (1986) issue of the journal Pain (Chronic Use of Opioid Analgesics In Non-Malignant Pain: Report of 38 Cases).  The problem is, his entire premise was based on this one study.  Not a meta-analysis of double-blinded, placebo-controlled trials, but 38 case studies. 

This study ended with a fair bit of pie in the sky. “We conclude that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.”  Not only have the numbers not borne this out, but not surprisingly, Dr. P “disclosed relationships with more than a dozen companies, most of which produce opioid painkillers,” to the WSJ.  Naturally, as do all physicians / researchers of similar ilk (HERE), Dr Portenoy claimed that being PAID BY INDUSTRY had / has nothing do do with his recommendations, professional opinions, research, writings, or talks.  All of which leads me to wonder how bad the Opiod Epidemic really is.

“Drug overdose deaths in 2016 most likely exceeded 59,000, the largest annual jump ever recorded in the United States.  Drug overdoses are now the leading cause of death among Americans under 50. Although the data is preliminary, the Times best estimate is that deaths rose 19 percent over the 52,404 recorded in 2015. And all evidence suggests the problem has continued to worsen in 2017.”  From the June 5, 2017 issue of the New York Times (Drug Deaths in America Are Rising Faster Than Ever) by Josh Katz

Honestly, you don’t have to look far as it is routinely on the 6:00 News.  CVS Health (By the Numbers: The Prescription Drug Abuse Epidemic) recently stated that, “The statistics are startling: 40 Americans die each day from prescription opioid overdoses.  In 2014, nearly two million Americans abused or were dependent on prescription opioids.  Nearly half of youths who inject heroin started out by abusing prescription drugs.”  The medical daily STAT recently revealed that over 250,000 people have died from opiod OD since Y2K.  They went on to say that, “Deaths from opioid overdoses jumped 17 percent in 2014. Since 1999, the number of deaths has increased fivefold.”  But despite the statistics, we still have not answered the question at hand — are our current policies on Narcotics / Opiods working for patients struggling with Chronic Pain?

In January, Dr. James Campbell published a piece for the journal Pain called The Fifth Vital Sign Revisited.  This was essentially his defense of the modern policies of pain management that were being attacked by several current studies, articles, and books (one we will discuss in a moment).  After mentioning things like FIBROMYALGIA, CENTRAL SENSITIZATION, ANXIETY / DEPRESSION, he discussed something I have oft discussed on my site — the FAILURE OF ADVANCED IMAGING as it pertains to detecting the cause(s) of Chronic Pain. 

Campbell wrote that, “It is instructive to consider that there is often a disconnection between x-rays and reports of pain in areas of the body other than the lumbar spine. For the hip, the knee, the shoulder, and other examples, the level of disease and the level of pain are only weakly correlated. A small tear of the rotator cuff may be very painful whereas large tears may be associated with no pain.”  He went on to say that, “The assessment of pain intensity should go beyond thinking about whether to write a prescription for an opioid.”  But here’s the rub.  For the most part, this is exactly what the average doctor is not doing.  For Pete’s sake; how can they think about anything of value (such as you, the patient) when they spend three fourths of a patient encounter staring at their computer and CLICKING A MOUSE?  Campbell goes on to reveal that….

“Often our failure to understand the pathophysiology of a disease affects our attitudes about the symptoms.  Back pain problems dominate pain clinics.  It is possible that the greater anatomical complexity of the lumbar spine makes pain management much harder from the perspective of biomechanics.”

Which brings up another question: Why haven’t doctors (Ponteroy included) been referring to the real experts on mechanical low back issues —- those who do it day in and day out, day after week after month after year after decade — Chiropractors?   You and I both know the answer to this.  Bias.  And bias always comes down to two things — pride and money. 

Although medical bias against Chiropractors is much less severe than it used to be, trust me when I tell you that it still exists in all its grandeur (HERE, and HERE are two recent examples).  And let’s face it; there’s a lot of potential income to be lost in referring patients to someone who might actually solve their problem, simply because they addressed the underlying biomechanical issues (HERE is one example of many on my site).  For the record, his piece concluded with this reassuring disclosure.J. N. Campbell serves as President, and Chief Scientific Officer of Centrexion Therapeutics, a company aimed at the development of new therapeutics for the treatment of pain.

  • Fifteen years ago this month, the Journal of Intravenous Nursing (Pain as the Fifth Vital Sign) revealed that medical groups were still largely on board with the attitude espoused by the Kinks back in 1981 — Give the People What They Want.   “Patients who do not report pain and healthcare providers who fail to assess for pain are major barriers to the relief of pain. Using pain as the fifth vital sign and being knowledgeable about pain assessment and management can help nurses and other healthcare providers overcome many of the barriers to successful pain control. A successful pain control plan includes establishing the pain diagnosis, treating the cause of the pain when possible…”    OK.  But let’s be totally honest with each other for a moment — candid if you will.  With huge numbers (probably more than 50%) of CHRONIC PAIN PATIENTS never receiving an accurate diagnosis in the first place (HERE), how do doctors hope to treat the cause of said pain — especially when they don’t really grasp much of anything on THIS PAGE?
  • By 2006, doctors and researchers were starting to sing a different tune.  The June 2006 issue of the Journal of General Internal Medicine (Measuring Pain as the 5th Vital Sign Does Not Improve Quality of Pain Management) determined that, “The most commonly used method to assess pain as a 5th vital sign is the 0 to 10 pain numeric rating scale (NRS). The NRS has robust psychometric properties in research applications, but how the NRS performs in routine outpatient practice is less certain.”  Isn’t it always interesting how real life patients never quite behave or respond like those involved in studies?  Final conclusions (the study’s title gave it away) were that, “the accuracy of the 5th vital sign for pain assessment is…. much lower in practice than under ideal research circumstances.  Efforts to improve routine pain management can confidently use NRS, but provider training, education, and monitoring in screening techniques are needed, as are efforts to link the 5th vital sign to clinician action for better pain management.
  • As time chugs forward, things are, in the words the immortal Merle Haggard, ‘rolling downhill like a snowball headed for hell,’ for those in the ‘Treat-All-Pain-Now’ camp.  Two years ago this month, Research Gate carried a study called Making Pain Visible: An Audit and Review of Documentation to Improve the Use of Pain Assessment by Implementing Pain as the Fifth Vital Sign.  Plainly stated, they concluded yet again that even though, “Pain has been promoted as the fifth vital sign for a decade, there is little empirical evidence to suggest that doing so has affected the care of individuals suffering pain.
  • And within the past six months, this message is becoming clearer than ever.  Writing in the January edition of Pain, Drs. Sullivan (Executive Director of Collaborative Opioid Prescribing Education) & Ballantyne (President of Physicians for Responsible Opioid Prescribing) wrote an article called Must We Reduce Pain Intensity to Treat Chronic Pain? (this is the article that was so hotly refuted by Dr. Campbell earlier).  Likewise, the two wrote an article for the New England Journal of Medicine about five months ago titled Intensity of Chronic Pain — The Wrong Metric? They did a great job of recapping this entire issue by laying the problem out on the table for all to see (cherry-picked due to time constraints).

“During the late 1980s and early 1990s, it was argued, largely on moral grounds, that opioids should be available for treating chronic pain, and physicians were persuaded that addiction to opioid treatment would be rare.  But is a reduction in pain intensity the right goal for the treatment of chronic pain? We have watched as opioids have been used with increasing frequency and in escalating doses in an attempt to drive down pain scores — all the while increasing rates of toxic drug effects, exposing vulnerable populations to risk, and failing to relieve the burden of chronic pain at the population level.

For many patients, especially those who have become dependent on opioids, maintaining low pain scores requires continuous or escalating doses of opioids at the expense of worsening function and quality of life. And for many other people, especially adolescents and young adults, increased access to opioids has led to abuse, addiction, and death. 

Pain-intensity ratings aren’t necessarily a reflection of tissue damage or sensation intensity in patients with chronic pain.  The intensity of chronic pain can’t be reliably predicted from the extent or severity of tissue damage, since chronic pain is not determined primarily by nociception.  For three decades, there has been hope that more liberal use of opioids would help reduce the number of Americans with unrelieved chronic pain. Instead, it produced what has been termed an epidemic of prescription-opioid abuse, overdoses, and deaths — and no demonstrable reduction in the burden of chronic pain.

Understand that I fully realize that there are people out there for whom NARCOTICS (opioids) are a necessity.  At least for a season.  I also know people — good people; upstanding and productive citizens — who have, due to any number of circumstances (often times severe injuries), gotten themselves hooked on these drugs.  Why?  Because, as RUSH LIMBAUGH would tell you, when it comes to narcotics, what works today will not work tomorrow — it always takes just a little bit more. The authors also mention the fact that chronic pain is not primarily determined by nociception.  If you are one of the tens of millions of Americans living with Chronic Pain, it is critical that you understand why (take a look at THIS SHORT ARTICLE on Type III Pain).  Not having access to narcotics leaves you with a few different options as far as dealing with your Chronic Pain is concerned (note that I did not list obtaining the drugs illegally as an option).

  • SUCK IT UP:  For some people, this is exactly what needs to happen.  Be aware that if you are addicted to pain meds; when you go off of them it could be mean several weeks of hell. 
  • DEAL WITH INFLAMMATION:  I have shown you about a million times (HERE and HERE are a couple of them) that Inflammation is the root of virtually all diseases (even A NUMBER OF THEM that people would rather blame on genetics) as well as Chronic Pain.  Figure out what is driving Inflammation in your body, and get rid of it (preferably without THESE DRUGS).  I have created you a helpful checklist (not by any means exhaustive) to at least get you thinking about what it will take to undertake this bullet point (HERE).
  • TISSUE REMODELING:  I have seen many many people over the years whose problems lie in a tissue that is not only the most pain-sensitive in the body, it does not show up on MRI.  As you might guess, this is a nasty combination — one that leads to accusations of malingering, drug seeking, trying to get on Disability, and mental instability / deficiency.  This is why, even if you do have Centralization (Type II Pain), you have nothing to lose getting treated if you think your problems / pain might be based in Fascial Adhesions (HERE).
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