Wednesday, February 24, 2016

Opinionated on Opiates and the Treatment of Pain -- Independent and Strong Sports Medicine Physicians and Our No Opiate Rule

President Obama just allocated $460 million to states to bolster resources to treat opiate-abuse disorders.  The goal apparently is to reduce opiate-related deaths, which are on the rise, especially amongst middle class whites.

I disagree with President Obama and his advisors when it comes to managing opiate-related concerns.  This is throwing money at the back end of the problem, tantamount to pouring extra water on an already extinguished house fire while an arsonist is next door dousing surrounding homes with gasoline and carrying a lit match.  Soon you're gonna have a bigger problem with which to deal.

The problem is opiates are catastrophically overprescribed.  This practice stems from the pharmaceutical industry led movement that began in the 1990's. I recall enjoying what seemed to be weekly free lunch provided for by a pharmaceutical company peddling their opium-derived drug.  A well-paid physician stood in front of me lecturing on the drug while my free boxed lunch set off 'triple point' endorphins as I ate my delicious sandwich, chips and chocolate chip cookie, pocketed between 1 and 10 shiny new drug-logo pens, and naively sat marveling at my having 30 additional minutes of free education as a school-loan supported medical student in New Jersey  that bolstered the idea that "pain is a "vital sign" to be measured routinely and monitored over time by your doctor at every visit like your temperature, heart rate (pulse), respiratory (breathing) rate, and blood pressure.  Pain is not a vital sign.  It cannot ever truly be a vital sign.  A vital sign must be objectively measured, by a reliable and trained health care provider or medical device.  Pain is subjective, and only measured by patient report. 

Opiates are reportedly prescribed to treat pain by physicians or other licensed non-physicians. 

Sadly, I report that I also fell victim to the influence of Big Pharma.  My 'retrospectoscope' now clearly places my naive self in the very center of the problem.  I am fortunate to be a reformed opiate prescriber.  Our office does not prescribe opiates.  I am often asked by colleagues how we can 'manage' to not prescribe opiates as they admit to wishing to stop prescribing them as well.  I would bet that a clear majority of physicians would choose to stop prescribing opiates entirely if they felt it was moral and ethical to do so...the problem is we were taught otherwise to more aggressively treat pain and prescribe opiates even if unsupported by evidence.  Taking opiates carries the risk of addiction, pseudoaddiction, tolerance, gastrointestinal side effects, impaired brain function, and as we know from well publicized media reports, death from opiate overdose.  Great financial windfalls are enjoyed by Big Pharma, and a growing illegal black market triggering many patients treated for seemingly legitimate concerns to divert some or all of their medication for cash.

In an era proscribing to adhere to 'Evidence-Based Medicine' I should point out that the pain research supports a clear absence of functional restoration for opiate users.  This means that persons taking opiates for pain do not demonstrate improved function in their daily life -- perhaps most importantly and objectively measurable, they do not return to work at higher rates than non-opiate users with pain.  As would be expected, opiate users do report higher quality of life scores.  Opiate drugs contain the same active ingredient as opium (same as heroin) and when they bind to our cell opiate-receptors provide one with a sense of euphoria.  We can probably agree that we're likely to rate our quality of life fairly high at a moment of euphoria?!!!

Opiates treat suffering moreso than pain.  Suffering ensues when pain is associated with a decline in function (e.g. inability to work or play), loss of control, and/or a decreased quality of life perception.  Opiate triggered euphoria transiently solves suffering.   What a wonderful concept for the cancer patient on her deathbed, or the battlefield wounded who may not survive his injury -- we can alleviate suffering at such a critical time.  However, pain is not suffering.  Pain is our bodily response to physical or psychological distress.  We need to experience pain to inform how we manage and hopefully cure such physical or psychological distress.

Nowhere is the distinction between pain and suffering more evident than in sports medicine.  Athletes overall are very high functioning individuals motivated to get better to return to their sport.  When they present to me relatively early on following injury, they typically have pain that resolves in a predictable manner with activity modification and therapeutic exercise.  They then return to play and their pre-injury high level of function.   Suffering may develop in the athlete unable to cope with their functional decline and/or if the athlete perceives a loss of control or decrement in life satisfaction.  Fortunately, most athletes have a wonderful capacity to heal and often have strong coping skills and positive life outlook.  This helps most athletes avoid pain-related suffering.

I have learned quite a bit about pain and suffering through my own personal experience.  I had spinal surgery for a disc herniation and nerve damage in 2007.  I dealt with high levels of pain before surgery and more mild-moderate levels of pain following surgery.  However, I escaped the realm of suffering.  I did not once use opiate medications before or after surgery.  How (or why) one might ask?  My pain did not transition to suffering due to my deep understanding about what my body was going through.  I did not feel worried or anxious as most people do because I knew why my body hurt and why my leg was weak and numb.  I understood my surgical and non-surgical choices. 

I can understand why physicians and other health care providers might wish to prescribe opiates to patients who present with suffering.  I think we are easily drawn to be overly empathic in the face of suffering, wanting to use our anti-suffering killer miracle drugs, readily losing objectivity and forgetting that opiates are not indicated for non-malignant pain (i.e. terminal cancer).  But unfortunately on some level we ignore our oath to 'first do no harm.'  We often treat our own anxiety, because it is easier to sign an opiate prescription than to recognize, diagnose, and treat suffering.  I don't know how to treat suffering in a brief office visit...but I'm very adept at recognizing it.

I agree we need resources directed towards treating these needy and suffering individuals who now are most often treated with opiates.  Funding should be directed to the training of additional mental health providers who are expert in recognizing, diagnosing and treating suffering, and appropriate public health messaging.  Teach people the difference between pain and suffering. 

While I entertain a discussion on the topic of opiates and the confounding health messaging by the pharmaceutical industry, our government, and the media, I am reminded of what I believe to be the true definition of health care:  health care is what happens in a closed room between a physician (which, by the way, comes from the Greek word for 'teacher') and a patient.  Health care does not happen in the local, state or federal legislature, in the boardrooms of pharmaceutical or medical device manufacturers, or in the offices of media executives -- that is where power is heralded.  Let us be transparent and clear.  In an age where more doctors are employees of hospitals or large health-care systems than self-employed, and more often considered merely interchangeable and 'evidence-based guidelines' technicians or line-workers, health care consumers are at risk of losing the opportunity to have individualized medical care provided by unconstrained independent thinkers.  As my fabulous partner and famously independent thinker, Gary Chimes, often chirps, "people who want great medical care deserve doctors too."