chronic pain

Chronic pain, opioid abuse and my first drug test

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I’ve been in chronic pain, defined as pain that persists for greater than three months, since my car accident in 2002.  I’m a staunch believer the medical community–from PCPs to surgeons to pharmacists and even to the CDC and insurance companies–are primarily responsible for the current epidemic of opioid abuse.  Inappropriate and overprescription of opioids by physicians and lack of followup and tracking by physicians, pharmacists and insurance companies have set up patients for abuse.  Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2010, without an overall change in the amount of pain Americans report.(1)  “An estimated 1 out of 5 patients with non-cancer pain or pain-related diagnoses are prescribed opioids in office-based settings.”(3)

In March 2016, the CDC  came out with twelve recommendations aimed primarily at PCPs, including

  1. Nonpharmacological (cognitive behavioral therapy (CBT), exercise therapy, etc.) and nonopioid (NSAIDs, acetaminophen, cortisone injections, etc.) treatments are preferred.  If opioids are used, use concurrently with other treatments.
  2. Opioid pain medication should be slowly advanced (starting with lower categories and progressing upwards), and with the immediate-release form (vs. long-acting) in the lowest effective dose possible.
  3. Prescribe for lowest effective duration, which may be less than three days vs. the often prescribed seven day course for acute pain.
  4. Discuss treatment goals and realistic benefit and risks with patients.  For new opioid patients, evaluate after 1-4 weeks; evaluate long term use patients every three months or sooner.
  5. Monitor the patient’s history of controlled substance prescriptions using state prescription drug monitoring programs (PDMP).
  6. Annually perform urine drug testing.(2)

Among the rationale used by the CDC for creating these recommendations was that  physicians feel they’ve been “insufficiently trained in prescribing opioids” and “find managing patients with chronic pain stressful.”  If a physician doesn’t feel adequately trained to prescribe a drug, why would they even consider prescribing that drug ?  Why are PCPs prescribing opioids at all? It baffles me that the first four “recommendations” weren’t already considered common sense, especially when the CDC goes on to state that across specialties, physicians believe, “long-term opioid therapy often is overprescribed for patients with chronic noncancer pain.” (2)

Due to changes in MA controlled substance laws following the latest CDC recommendations (specifically 5 and 6 listed above), I recently had my first ever drug test and had to sign a narcotics agreement (9), because I take Tramadol.  In the years following my car accident, I’ve tapered down from Morphine/Oxycontin (three weeks in hospital) to Oxycontin/Percocet (quickly got off Oxycotin AMA after returning home) to Percocet (eight months until attempting to return to work in 2003) to Vicodin/Percocet (several years) to Tramadol/Percocet and finally to Tramadol (haven’t taken a Percocet since I started Baclofen in 2013).  I find it odd, with all the narcotics I’ve taken over the last fourteen years, it’s Tramadol that’s finally requiring I be followed for potential abuse.  I take 100mg twice a day; the maximum dosage is 400mg. I feel pretty certain if I hadn’t been the one pushing to decrease the amount of narcotics I was taking, I’d likely be physically dependent on Percocet, as are so many other chronic pain patients.

In 1990, my partner at the time and I each had surgery:  my partner had a lump removed from his forearm in early 1990, then I had shoulder surgery in December 1990.  In both instances, the surgeons urged us to take Vicodin and Percocet respectively, despite each of us requesting Motrin for pain.  When we objected to the opioids, both surgeons told us not to come back to them whining about being in too much pain.  We each took only a few Motrin for pain relief.  In my case, my right arm was immobilized for six weeks and then required extensive rehab, but I still didn’t need opioids.

Most of the three weeks I was hospitalized following my car accident, I was too out of it to pay attention to what narcotics I was being given.  Once home, when I learned of the highly addictive nature of Oxycontin, I told my surgeon I wanted off of it.  He protested and said I needed to stay on it longer to adequately control my pain.  Having been through this before, I told him he could take me off it or I would do it myself.  He reluctantly agreed.

Piecemeal recommendations and changes in opioid management have been the norm for several years, but different states continue to have different requirements for how they handle opioids.  As of 2012, across the country the number of painkiller prescriptions per 100 people ranged from 52-143!(3)  Why are physicians writing so many opioid prescriptions, and why are they clustered in certain areas of the country?  If the stats I’ve provided aren’t shocking enough, a recently published study of 3000 patients who’d overdosed on opioids showed that 90% of them were put back on opioids after their overdose!(4)

It seems the opioid epidemic is finally being addressed across many levels of government and medical professionals.  Here’s a few examples:  In April 2016, amid pressure from the White House, more than 60 U.S. medical schools pledged to teach new federal guidelines for prescribing opioid painkillers.  Currently most med students only receive a few hours of instruction on prescribing opioids throughout their four years of med school.

Tufts Medical Center ED has seen its total number of narcotics prescriptions, as compared to total prescriptions written, decrease from 18% to 11% from January to August 2016.  At their monthly meeting, they simply began displaying PowerPoint slides showing the number of narcotic prescriptions written by each ED doc, without comment. Simply by seeing the differences in the number, higher prescribing physicians have reduced the number of narcotic prescriptions they write.(5)

Led by Massachusetts governor Charlie Baker, 44 governors have agreed “to adopt a common set of strategies to fight opioid addiction, signing a compact modeled after policies that have already been implemented in Massachusetts.”(6)

Among the arguments Dr Tanya Feke makes as to why doctors didn’t cause the opioid epidemic, she believes regulations have forced doctor’s hands in prescribing more opioids.  An increased focus by Joint Commission on Accreditation of Healthcare Organizations (JCAHO) on pain as a vital sign (think of all those pain scale posters) has changed medical practice.  Patients often give low scores on patient satisfaction surveys if their pain isn’t “completely” controlled or if they requested opioids and didn’t receive them.  When such surveys are tied to financial incentives, doctors can feel as though their hands are tied.(7)

Everyone’s getting on board, right?  Well not exactly.  In April 2016, amid little opposition or media attention, the Ensuring Patient Access and Effective Drug Enforcement Act of 2016 was passed and signed into law.  “Critics say it takes pressure off companies to detect and report drugs flowing to the black market. The top DEA official for regulation of pharmaceutical firms left the agency last fall, in part, he said, because of a bitter dispute with members of Congress over his view that the bill was misguided and would worsen the epidemic.”(8)

One example is Purdue Pharma, who’s made more than $31 billion from Oxycontin. Purdue collected extensive evidence of a drug ring but didn’t notify law enforcement or take any measures to stop the supply of pills. Essentially, the law gives big pharma little incentive to prevent abuse unless the DEA accuses them of violating the law. (8)

Without a willingness to view addiction as a chronic illness and not a moral failing (a call being made by the current Surgeon General Vivek H. Murthy, M.D., M.B.A.) and increased funding for addiction and mental health treatment in general, can we really expect any significant resolution of the epidemic?

REFERENCES AND NOTES

  1. Centers for Disease Control. Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999–2008.   MMWR 2011; 60(43);1487-1492. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w%20-%20fig2.
  2. Centers for Disease Control. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR 2016; 65(1);1–49.  http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
  3. Centers for Disease Control. Injury Prevention & Control: Opioid Overdose.  March 16, 2016.  http://www.cdc.gov/drugoverdose/data/prescribing.html
  4. Suzuki, Joji. Why are doctors writing opioid prescriptions — even after an overdose? Harvard Health Blog.  January 28, 2016.  http://www.health.harvard.edu/blog/why-are-doctors-writing-opioid-prescriptions-even-after-an-overdose-201601289060
  5. Kalter, Lindsay. Tufts reports drop in ER opioid prescriptions. Boston Herald. August 31, 2016.  http://www.bostonherald.com/news/local_coverage/2016/08/tufts_reports_drop_in_er_opioid_prescriptions
  6. Schoenberg, Shira. Led by Gov. Charlie Baker, 44 governors sign compact to address opioid addiction.  masslive.com.  July 13, 2016.  http://www.masslive.com/politics/index.ssf/2016/07/led_by_gov_charlie_baker_44_go.html
  7. Feke, Tanya. I am a doctor, but I didn’t cause the opioid epidemic.  www.kevinmd.com. May 26, 2016.  http://www.kevinmd.com/blog/2016/05/doctor-didnt-cause-opioid-epidemic.html
  8. Ryan, Harriett and Christensen, Kim. Amid opioid epidemic, rules for drug companies are loosened.  LA Times.  July 17, 2016.  http://www.latimes.com/local/california/la-me-pharma-bill-20160728-snap-story.html
  9. The attached narcotics agreement is the actual agreement and risk assessment included in my medical record. It can be difficult to know what these things really look like, so feeling like there wasn’t any personal information I hadn’t already made public on this blog, I decided to go ahead and link to it in its entirety.