Two contemporary issues have apexed into the most discomforting tension. On the one hand, the medical profession has been accused of undertreating pain. This is not a new criticism and it has been unfortunately proven to be accurate, again and again.1 On the other hand, however, the medications used to treat severe pain are under increasing assault for their abuse potential. As primary care professionals, it is high time to frame and discuss this critical tension further. Soon, our responsibility in writing these prescriptions may be punished under the law.
The Two Debates
It has been estimated that approximately 50 to 75 million Americans suffer from chronic pain.2 That pain comes with its own prohibitive personal burdens for the sufferers and cannot be ignored by our profession. The cost to families and society is also high; loss of job productivity ensues and suicide may be the only escape from pain.2 In fact, one estimate valuated the economic downside of chronic pain at $61.2 billion a year a decade ago3—and that number has only increased. If these statistics are not disturbing enough, there is additional data demonstrating the undertreatment of pain in palliative or terminal clinical situations. For people in the last hours of life, and their families, this is unacceptable.
The other side to this societal “pain” debate revolves around the ostensible potential for the abuse of pain medicines. A 2006 survey indicated that 4.7 million Americans used a prescription opioid illegally.4 Other concerns include the use of oxycodone and other similar drugs as a “gateway”5 to heroin addiction and the fear that prescriptions may fall into the wrong hands and prosper in the black market.
Possible Scenarios
Where are we as a society in resolving these tensions? We may be a bit like our lawmakers in that diametrically opposed extremes may impede consensus. One extreme may lead to concerted Drug Enforcement Administration (DEA) regulation and criminalization of painkillers, with physician prescribers as targets. There is precedent for such behavior: In 1914, the Harrison Act outlawed the nonmedical use of opium, morphine, and cocaine—making it illegal for a physician to prescribe narcotics to an addicted person.2 Between 1914 and 1938, approximately 25,000 physicians were arrested under the aegis of the Harrison Act.2 If the DEA undertakes a similar regulatory approach today—aimed primarily at physicians—would we as a society merely be repeating the mistakes of the past?
The other extreme does away with the tension altogether but may be considered overly intrusive (eg, online reporting sites tabulating prior prescription use and urine testing). One author, in particular, awakened me from any dogmatic slumbers regarding prescription painkillers by implying that physicians are “moralizers” and withhold narcotics from the poor assuming they are addicts. I cannot consciously remember ever doing that. But, in her defense, she was protecting pain sufferers from being abandoned when most in need.
Is there a middle ground? Since this readership has a lot to lose if a contemporary Harrison Act is enacted, your comments would be greatly appreciated. Here are some points to consider:
Physicians are still undertrained in pain management. Some of the reliance on narcotics stems from physician discomfort with others’ pain. Physicians also may unreasonably swing to the other extreme and worry inappropriately about addiction in people who really need ongoing pain relief. This unpreparedness has to be remedied with substantive (not window dressing) curricular change in medical school, and in all residencies and fellowships. All physicians deal with pain. Part of this education has to be aimed at teaching physicians to identify drug-seeking behavior as well.
Online recording systems and urine testing may not be intrusive—as long as they are only between doctors and their patients. These safety measures are doctor–patient, mutually agreed upon contracts for behavior while on narcotics. The model for doctor–patient relationships today, far and away, is a contract. When someone tells me they have pain and I prescribe a pain medication, is it wrong to ensure that the pain medication not become part of a “cocktail” that also includes marijuana, cocaine, and alcohol? If I contribute to a fatal overdose, that is contrary to my role as a physician. If the pain contract stipulates certain exclusions for the patient’s welfare, they should be followed.
Avoid excessive DEA regulation. I think excessive DEA regulation with punitive actions against physicians is wrong-headed and will be no more successful or long-lived than the Harrison Act or its unfortunate temporal sibling, Prohibition.
Pain medicines should be prescribed or withheld based on a carefully performed history and examination. They are not a panacea for back pain without physical therapy or imaging in the appropriate circumstances (radiculopathy, history or suspicion of cancer, and fever). Patients should not be told they do not have pain without a careful assessment. The benefit of any doubt goes to the patient.
Urban legends have to be corrected. I am not convinced that oxycodone has been proven unequivocally to be a gateway drug.5 Some have even inquired whether recent media hype has actually contributed to the popularity of oxycodone.6
We need more pain medicine specialists. We need to consult palliative care and hospice earlier and more frequently. If we are not expert in pain and its relief, we need access to those who are.
Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.
References:
1.Moskovitz BL, Benson CJ, Patel AA, et al. Analgesic treatment for moderate-to severe acute pain in the United States: patients’ perspectives in the Physicians Partnering Against Pain (P3) survey. J Opioid Manag. 2011;7(4):277-286.
2.Libby RT. Treating doctors as drug dealers: the DEA’s war on prescription painkillers. Cato Institute. Policy Analysis. 2005;545:1-28.
3.Stewart WF. Lost productive time and cost due to common pain conditions in the U.S. workforce. JAMA. 2003;290(18):2443-2454.
4.Walsh SL, Nuzzo PA, Lofwall MR, Holtman JR Jr. The relative abuse liability of oral oxycodone, hydrocodone, and hydromorphone assessed in prescription opioid abusers. Drug Alcohol Depend. 2008;98(3):191-202.
5.Grau LE, Dasgupta N, Harvey AP, et al. Illicit use of opioids: is Oxycontin a “gateway drug”? Am J Addict. 2007;16(3):166-173.
6.Braun L. The dilemma of prescription opioids: shifting attention toward the pain patient. The Public’s Health. 2014 Mar 19. Available at: www.philly.com/philly/blogs/public_health/The-dilemma-of-prescription-opioids-shifting-attitudes-towards-the-pain-patient.html. Accessed April 2014.
