By Garry Moore, MD
This article is not intended to
explore all the issues surrounding
chronic pain; my only goal is to
convince the readers that it’s okay to
be an“opiophobe”.
I’m not talking about the elderly
patient or one seriously limited by
conditions such as poly-arthritis,
malignancy or fatally debilitating disease.
I’m talking about the patient who
is balanced in life with its vicissitudes
but has some bio-psycho-social event
that tips them out of balance, and they
decompensate. The decompensation is
most obviously demonstrated by the
symptom of pain. Not a lot of signs,
(except perhaps pressure at a few scattered
points might cause pain, if you
consider that a sign) just pain, not evidence
of any particular loss of function,
just pain.
If that patient sees the typical primary
care doctor we will look for a
physical condition that needs to be‘fixed.’ We won’t find anything, then
after a few weeks of frustration we refer
them to a pain medicine doctor.
By definition, the pain medicine
doctor wants to relieve pain. Among
their ranks are some truly wonderful
people. Mother Theresa, Albert
Schweitzer and your local board certified
anesthesiologist turned pain management
specialist, they could be a
team working seamlessly together.
With my obvious sarcasm, I don’t
mean to disparage pain management,
but is chronic pain really an opioid
deficit? There is no other rational
explanation for the long term use of
narcotic pain relievers. We all know it
is a one way street for the vast, vast
majority of patients who get on long
acting, high-potency opiates.
So what, getting on Synthroid,
insulin, lisinopril or Zocor is a one
way street too, right?
Isn’t chronic pain fundamentally
different than hypothyroidism or
hyperlipidemia? Is it likely that a
patient coping with life, has an event
that causes minimal tissue damage but
depletes their body of endorphins so
profoundly that for the rest of their life
they have to have opioid supplements?
I don’t think so. I think it’s more
likely the “event” has become an
excuse for the patient. The symptom
they present with is relatively easy and
gratifying to treat (perhaps only the
dermatologist has a more grateful
patient population, at least for the first
few months) and the opiophiles say
it’s safe. Alternatives are extremely time
consuming, difficult to code for,
(patients have a blind trust in a prescription
but have to be convinced to
try something non-pharmacologic) so
why not?
We remember the best part of being
a doctor is to relieve suffering, and opiates
have got to be one of Gods greatest
gifts to humanity for that purpose,
but there is that other part of medicine— do no harm.
If narcotics just fill a physiologic
need, why aren’t the patients better
when given the opiates? Better of course
becomes hard to define since there wasn’t
a lot of obvious concrete deficits to
begin with, we only have two things to
measure: Where did it go on the pain
scale? (From a 9/10 to a 5/10 would be
considered a success). The second is
function. My practice is limited to workers’
comp, but from what I see narcotics
never improve function!
From my experience in San Antonio,
if a patient is referred to a pain management
specialist their chance of
returning to the same level of functioning
as they enjoyed before their work
related event is almost zero.
Of course there are a lot of selection
bias issues to discuss, but the question
why aren’t patients better, i.e. more
functional, after treatment with opiates
is still valid. One of the conclusions of
a large Danish study of pain stated,“However, it is remarkable that opioid
treatment in long term/non-cancer
pain does not seem to fulfill any of the
key outcome opioid treatment goals:
pain relief, improved quality of life or
improved functional capacity.”
One reason the narcotic treated
patient is not much more functional is
that the drugs are CNS depressants.
Some enterprising pain doctors then
treat the dull lethargy associated with
opiates with amphetamines! Honest
they do, or they might use Ritalin or
Provigil, but does that make sense?
Opiates relieve suffering, maybe
they don’t improve function, but are
they doing any harm? In the general
population 10 to 12 percent have true
addictive disorders. In the chronic pain
population it is at least that high. Does
it seem okay to prescribe drugs where
you know 10 percent of the patients
will have a true addiction and be struggling
against a drug stronger than they
are for the rest of their lives?
To put it in perspective, the FDA
considered the .005 percent of patients
taking Rezulin who suffered liver damage
to be unacceptable, so that drug
was removed. More recently .1 percent
of Zelnorm users have had cardiovascular
side effects. That was considered
too high a risk, so now Zelnorm is
gone. Yet the opiates are okay with at
least a 10 percent serious addiction
problem? (I suspect we all accept the
risk and want these strong opiates
available because we fear that some
day we too will be in serious pain.)
I had a family member taking
OxyContin 40 mg three times a day for
her neuropathic pain. It and other
drugs literally stole four years from
her; eventually she suffered painful
withdrawals and then got on with her
life coping with her pain without narcotics.
She was definitely worse off
than she was before the narcotics.
As a National Guardsman, I was
involved in the aftermath of both
Katrina and Rita. I witnessed many sad
cases of evacuees wandering about desperately
looking to satisfy their iatrogenic
narcotic addiction.
The mortality associated with these
narcotics is difficult to quantify but consider,
in 2002 there were more deaths in
the U.S. due to prescription opiates than
to cocaine and heroin combined.
The drugs were prescribed to mostly
peri- and post-menopausal women, but
the deaths were in younger men. So,
what violence must the women have
suffered for the drugs to go from them
to the men? Imagine if the ladies had
also been prescribed amphetamines to
counteract the narcotics.
There are many cases in history
where mainstream medicine tried to
relieve suffering but ended up making
it worse. I see it all the time on a
smaller scale with excessive use of
slings and braces. Another common
one is steroids in multiple sclerosis.
In the old days, everything was treated
with bed rest, and we now know
how counterproductive that can be. I
suspect some chronic pain starts with
all the other neuroactive drugs we use,
from SSRIs to benzodiazepines, before
the event occurs. Imagine after a neuron
has been damaged by some event
and it can not remodel and regulate its receptors normally because there are
outside pharmacologic influences, so
chronic neuropathic pain ensues. If we
leave neurons alone they will repair
and remodel for us just as they did in
our grandparents’ time.
Is it just a coincidence that chronic
pain sufferers are three times more
likely to be smokers?
I think there is a lot we do not
know about this kind of chronic pain.
I strongly suggest the caring provider
consider non-narcotic treatments, from
acupuncture, to talk therapy to tai chi.
That is the best way to do no harm,
and it has a better chance of actually
helping a patient enjoy life.
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