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."
