Pain & Pain Medication

by Steve Heilig, April 18, 2012

A lot of Americans are in physical pain. A lot of Americans are addicted to prescription pain medications. The two populations overlap, but are not the same. And therein lies a huge and growing problem.

The New York Times recently printed a front-page story titled “Tightening the Lid on Pain Prescriptions.” The Wall Street Journal printed one on the same topic a week before. Clearly, more people are recognizing we have a serious problem — two of them, in fact. It’s long been demonstrated that pain has been widely under-treated in this country; a landmark Journal of the American Medical Association study about fifteen years back estimated that up to half of all patients with chronic pain got sub-standard treatment. Efforts to improve that have been underway for some time. But it’s also increasingly recognized that unwise use of pain medications is a growing epidemic, with dire results: Fatal, unintentional drug overdose occurs every nineteen minutes in this country, and opioid analgesics — oxycodone, for example — have been responsible for more of these deaths since 2003 than heroin and cocaine combined. And that’s just the tip of the abuse/addiction epidemic. For every such death related to opioid analgesics, 461 people report nonmedical use — abuse — of these meds, and 35 visit an emergency department. There, doctors learn to dread them — the patients who might be “drug-seekers,” or might be in real physical pain, or might be both (the rest of us dread running into the addicts most anywhere else).

But pain and addiction are not entirely mutually exclusive diagnoses. Addiction is painful — it has even been likened to slavery. And many addicts started as honest people in physical pain. Medication diversion and abuse has become a major epidemic. Up to three-quarters of non-medical opioid users report their drugs were prescribed to somebody else — in other words, they are sharing and selling them. Doctors do know this, and all but few try to walk a middle path between prescribing too many or withholding meds from people in pain. The science of pain and pain treatment has advanced considerably in recent decades, and many older doctors did not keep up with that knowledge. About a decade back, a case of underprescribing of meds, leaving a patient in horrible pain, resulted in a one-time requirement that almost all California doctors had to take a one-day class in pain treatment. Many, maybe most, were dragged there kicking and screaming. But many said afterwards that they were very surprised at how much they learned and how much it helped them in practice. Much more ongoing education is warranted.

Clearly there is much to be done in terms of addressing both epidemics of under-treated pain and pain medication abuse and addiction. We'll likely never get it perfectly taken care of. The relatively few “bad apple” doctors who indiscriminately write prescriptions, or even sell them in some manner, must be weeded out. For people nearing the end of life or in severe, intractable pain at any point, addiction should not be an issue, or a secondary one at most. We need more good pain specialists in more parts of the country; studies have shown that the further one is from a major medial center — e.g., San Francisco or Sacramento, in the case of Anderson Valley — the higher the likelihood is one might receive substandard pain care.

One important practical tool to help track the prescriptions of pain meds, the Prescription Drug Monitoring Program, is going underutilized and unfunded — there is so little staff for it that the program is basically a shell at this point. This “CURES” system allows doctors and pharmacists to “instantly look up the prescription histories of customers and refuse to provide medication to a patient whose drug shopping habits seemed suspicious or out of control. More than 40 states are using similar systems to help curb prescription drug abuse.” But it's not quite working in our state. The funds needed to upgrade and operate this neglected tracking system would no doubt prevent much higher costs elsewhere. So as is so often the case, the choice is between prevention or playing catch-up, aka, penny-wise or pound-foolish. And unfortunately pinching pennies usually wins out, and then we wonder why the problem is so bad while we try to clean up the consequences. Perhaps California politicians and regulators can see their way to an exception this time, for the benefit of all concerned.

And, I can’t help but add, this would seem to be a bigger problem than a few profiteering and corrupt cannabis clubs, annoying to some politicians as those might be.

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