A VIEW FROM THE OFFICE
Doctors Call For Pullback
On Narcotics For Chronic Pain
Courtesy of NPR: http://www.npr.org/blogs/health/2011/09/16/140540259/doctors-call-for-pullback-on-narcotics-for-chronic-pain?ft=1&f=1001
by Scott Hensley
September 16, 2011
Drugs such as Vicodin, Percocet and Oxycontin have become among the most prescribed in the country. Between 15 and 20 percent of patient visits with physicians the U.S. include a prescription for an opioid, the modern painkilling medicines whose roots can be traced back to the opium poppy.
But their editorial, published this week in the Archives of Internal Medicine, says there's a troubling shortfall in the evidence to support the use of such drugs for long-term treatment of pain. And, there's ample evidence of harm.
"Unfortuantely, the use of prescription opioids currently results in more deaths in the United States due to intoxication than heroin and cocaine combined," says Dr. Mitchell H. Katz, a co-author of editorial, in a podcast. "That's shocking."
Doctors' prescriptions for the medicines that are supposed to decrease pain and improve patients' ability to function, he says, are "killing more people than two drugs that we think of as lethal, so much so that they're illegal." The death toll from the legal pain pills is about 12,000 a year, he says. "It's a public health problem."
So what's their prescription? Until there's more scientific evidence, doctors "should not continue to prescribe high-dose opioids" for chronic non-cancer pain. Narcotic drugs for short-term relief of pain are fine, but Katz says there's insufficient evidence to support their use over the long haul.
Instead, doctors should talk with patients about the limits of pain relief and give alternatives to opioid drugs, such as physical therapy or yoga, their due. To some patients, doctors may need to give a sobering message, Katz says in the podcast: "This is not something I'm going to be able to completely take away."
The bottom line of the editorial, part of a series in the journal called "Less Is More," is that a rethink on these narcotics is overdue.
What do the pain specialists think? I asked for a comment on the editorial, and got a statement from Dr. Robert Chou, who heads the group at the American Pain Society working on guidelines for clinical practice.
While it's important for clinicians to be more thoughtful about who they prescribe long-term opioids to and to stop opioids when they aren't helping or there is evidence that it is causing problems, the American Pain Society believes opioids have a role in the management of chronic non-cancer pain in carefully selected and monitored patients.
There is evidence from long-term observational studies and evidence coming from some long-term clinical trials that opioids are effective for improving pain in some patients.
For example, we do not believe that a trial of low doses of opioids should be denied to a low-risk woman in her 70's who has severe hip arthritis, who may be able to garden and walk with decreased pain on it.
While the data on overdose deaths and abuse of opioids should concern all members of society, it does not justify an extreme blanket position of no opioids for chronic non-cancer pain.
No one has any objection to treating the acute pain of a sprained ankle, broken bone, or sprained back. These are generally 1 to 2 week situations. Of course, we all know plenty of people who have injured their back and are still taking pain medications 3, 6, 9 months later, perhaps even years later.
If you are an astute observer, what you will notice about these people after 6 months, 9 months, or a year, is that they are NOT getting any better. If one looks at it from a strictly objective point on view, the common theme to patients who take chronic pain medicines is that they do not get better. To this some will say, "That's no surprise. They have a condition which is just not going to get better." But what the experts have come to learn is that the mere fact of taking chronic, usually high-dose narcotics, actually and directly keeps you from getting better.
A lot of this, of course, depends upon how you define "better." The patient in chronic pain may simply prefer to be narcotized and out of it so as not to have to deal with life and his or her chronic pain. But pain, whether acute or chronic, is just a small part of life, and life can indeed go on.
The real test of the value of a pain medication in chronic use is whether it is helping the patient to achieve any of their well-planned goals and objectives for their life. For example, taking pain medication right before a painful physical therapy session so that you can get through the session and accomplish to work needed to heal is an excellent use of pain medication, no matter how long it goes on. On the other hand, pain medication that keeps you so foggy and energyless that you won't go out to social events, meet with friends, try something new means you're letting the pain medication kill you.
Thus the usual rule in the context of chronic pain is that most pain medications tend to hold you back from getting on with your life. They all do some terrible things to your system.
Everyone who takes chronic pain killers is going to experience severe constipation, and I mean constipation so severe that stool will be backed up all the way past your rectum, sigmoid colon, transverse colon, right colon, all the way to your appendix. This is a very uncomfortable, frankly miserable way to live. You'll be getting cramps every time you want to eat in the advanced condition and then start losing weight.
Chronic opiates all have an adverse effect on the cardiac electrical conducting system. Methadone is clearly the worst, but they all do it to some extent. They can lead to a condition called long QT syndrome, which can be fatal without warning. Many experts recommend a routine annual ECG for all patients on chronic pain medications just to try to detect this condition early.
The other bad news, particularly for men, is that chronic use of opioid pain medications leads to lower levels of sex hormones. Testicles can start to atrophy; libido goes down; actual serum testosterone levels can go quite low--to low to support adequate sexual function. (This also happens to some extent in women, but the exact effects are not as clear.)
So there are lots of reasons not to be very keen to keep using pain medications long after the time of initial injury.
On the other hand there are a whole host of things that have significant pay-offs. Consider some of these:
reading to the blind
being a big brother/big sister
adopting a child online
rescuing a pet
try alternative medicine
try physical therapy or chiropractic
consider non-habit forming pain adjuvants like antidepressants (amitryptyline, nortriptyline), gabapentin, etc.
pursue a new hobby (like photography, drawing, woodworking, jewelry, etc.)
become an expert on some subject of interest to you.
All of these tend to work towards the development of a better mind. All chronic pain medications work in the opposite direction of numbing your mind and stifling thought and creativity. To go and fulfill your special gift to the world you are going to need an alert open mind, a flexible outlook, and a willingness to try things, anything. If you consciously work on expanding your own possibilities you can build yourself a great palace in the sky and relegate the pain to the hall closet. You just have to think bigger.