Opiates Manage Pain Yet Present Dangers

April 1, 2016

Local Doctors Struggle for Balance

Physical pain sends us two very clear messages. First, it tells us something is wrong. In theory, improved diagnostic tools should then be able to determine what ails us.

For healthcare providers across northern Michigan and elsewhere, the second message is more urgent: we want to control the pain — right away. As author C.S. Lewis put it, “Pain insists upon being attended to. God whispers to us in our pleasures, speaks in our consciences, but shouts in our pains.”

The U.S. pharmaceutical industry has responded with a wide range of medicines – from over-the-counter drugs to a whole class of potentially addictive opioid pain “killers.” Millions of Americans find pain — on any level — unacceptable.

National Public Radio recently reported that the U.S. accounts for about 5 percent of the world’s population, but 80 percent of the world’s painkiller use.

This statistic does not surprise orthopedic surgeon Dr. Justin Hollander of Traverse City Orthopedic and Sports Medicine.

“I don’t doubt that for a second,” Hollander said. “And it’s only getting worse.

We’ve tried to eliminate pain and it’s created a beast. It has become uncontrollable. Patients now expect not to hurt.”

That expectation is unrealistic, said anesthesiologist Dr. Howard Beck at Munson Community Health Center, more commonly called the “Pain Clinic.”

“I’ve been doing pain management for more than 20 years,” he said. “The culture we live in is everything has to be taken care of now, and patients feel they deserve to be pain free. Many younger patients, in particular, want a quick fix.”

In the process, addiction to powerful painkillers has become an enormous, and sometimes deadly, social problem. Many state agencies are fighting back. The Michigan Attorney General’s office has responded with an aggressive campaign against healthcare providers it thinks are too freewheeling with opiate prescriptions. One example is Dr. Robert Townsend, owner of Denali Healthcare pain management clinics in Traverse City, Gaylord, Mt. Pleasant and several other Michigan cities. In December, the state suspended Townsend’s medical license over improper patient evaluation practices.

A Balancing Act for Prescribers

Not surprisingly, prescribers are developing stricter procedures before issuing opiates. Most practices rely on an in-depth interview of the patient, but other controls have become common.

Before issuing a prescription, many practices consult the Michigan Automated Prescription System (MAPS), a data source on controlled substances already dispensed to individual patients across the state. The goal of MAPS, and similar programs in other states, is to make it difficult for patients to get multiple prescriptions.

“Most practices use a consent to treat form for opioids management,” said Jill Fenton-Jones, manager of the Jones Center for Pain Management in Traverse City. “It’s basically a contract. There are monthly or bimonthly drug screens. Patients who break the contract get no more meds.”

Staff psychologists at Beck’s practice play an important role in screening potential patients.

“They study the patient’s psychological makeup and help determine whether an individual can take an opiate without becoming addicted to it,” Beck said. “And they help people learn how to live with pain.”

Patients suffering from depression or anxiety are generally considered poor candidates for using opiates, Beck said, “because both of those conditions can elevate one’s perception of pain signals.”

Many Causes, Many Types of Pain

Even with multiple controls in place, pain management is challenging.

“That’s because pain itself is a very complicated, multi-faceted physical, social and psychological phenomenon,” Beck explained. “And that’s why very few people are good at treating it.”

“First, you have to understand the difference between chronic pain and acute pain,” he said. “You treat those two things extremely differently. Chronic pain can almost be considered as a disease state. [At the clinic] We primarily treat chronic pain. It’s not like a surgery in which acute pain lasts for four or five days. And you have to understand the underlying condition that’s causing the pain, that requires a thorough diagnosis.”

Pain is Personal Another complicating factor for prescribers is that everyone experiences pain in her or his own way. For some, an overthe-counter remedy is enough. Someone else with the same ailment might clamor for something stronger. “Pain is an experience,” said Fenton-Jones. “And you can’t tell a person what they should be feeling.”

Addiction: A Real Danger For Some

Not everyone who uses opioid painkillers ends up an addict, but just as pain is a highly individualized experience, some patients are more prone to addiction that others, and the numbers of those who develop a serious problem are startling.

Drug overdoses have become the leading cause of accidental death in the U.S. and, according to the American Society of Addiction Medicine (ASAM), opioids are driving the epidemic.

Hollander said patients who experience pain very intensely or who exhibit addictive tendencies often become irate if turned down for powerful opiates.

“I face this every day,” he said. “I’ve even heard of patients threatening doctors’ families and their staffs.” That extreme pressure, he said, “makes it tempting for doctors to just give them what they want.”

Determining who really needs — and who can handle — potentially addictive painkillers is not easy. To avoid confusion, Hollander makes his ground rules clear from the very start.

“I tell them, ‘unless I cut you open, I don’t give out drugs,’” he said. “Most people can accept that. If they get angry after that, it tells me this person probably has other issues that need to be addressed.”

The Heroin Connection

Tighter oversight of prescription opiates has resulted in an unintended consequence: a dramatic rise in heroin usage. The ASAM reported 94 percent of respondents to a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.”

And northern Michigan is not immune to the problem. As reported in The Ticker last July, local law enforcement and healthcare professionals use terms such as “a freight train,” “a storm,” “a crisis” and “an epidemic” to describe the skyrocketing number of heroin users — and heroin-related crimes — in the Grand Traverse region.

What Patients Can Do to Avoid Pain and Addiction

Still, addiction is not inevitable. Patients, even those dealing with chronic pain, can take concrete steps to reduce the chances of becoming dependent.

Controlling weight can help. Patients who fall in a normal size/weight range generally heal faster, Hollander said. That can mean less pain and fewer meds.

Eliminating tobacco use also helps. “The issue for tobacco addicts is that the pain they experience doesn‘t get better,” said Beck. “They have a lot of degenerative disc and back pain, for example, and can’t heal because they smoke. If you quit, [the healing process] it improves.”

Emphasizing the Incremental Approach

Drs. Beck and Hollander, like many of their colleagues, take an incremental approach to pain management. Whenever possible, they choose a pain management course of treatment that poses the least potential for addiction.

From his perspective as an orthopedic surgeon, Hollander employs simple, noninvasive methods like icing as a natural antiinflammatory and having post-op patients elevate the leg that has been operated upon to reduce blood flow.

Other non-pharmaceutical, pain coping techniques include physical therapy, acupuncture, acupressure, chiropractic care, massage, hypnotherapy, meditation, pet therapy and, in the past few years, the new field of music therapy. Often healthcare providers use some combination of these treatment options.

Genetic testing can also help. “Because everyone has their own reaction [to meds], another thing we do is genetic testing to see what works best for them,” said Fenton-Jones.

Sharing the Responsibility

Clearly, prescribers of pain meds face increased scrutiny.

“A lot of good physicians have gotten into trouble,” said Fenton-Jones.

Patients also bear the responsibility for using prescription meds responsibly. They abuse painkillers at their own risk.

Facts About Opioids

• Opioids are a class of drugs that includes heroin as well as prescription pain meds like oxycodone, hydrocodone, codeine, morphine and fentanyl.

• The overdose death rate in the U.S. in 2008 was nearly four times the 1999 rate.

• Sales of prescription pain relievers in 2010 were four times those in 1999.

• The treatment admission rate for substance abuse in 2009 was six times the 1999 rate.

(source: American Society of Addiction Medicine)