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CHRONIC PAIN AND OPIATE ADDICTION
by
Lloyd J. Gordon, III, MD
Medical Director of COPAC
The United States has over 15,000 deaths from opiate overdoses a year and over 30,000 total drug related deaths. This is more than the number of people that die in automobile accidents. Depending on the data source, the United States consumes 80% to 99% of the legal opiates in the world. Over the past 15 years there has been a distinct change in the culture of the practice of medicine related to pain. From 1999 until 2008, I was one of the delegates of the American Society of Addiction Medicine to the American Medical Associations House of Delegates. During this time the various pain societies were pushing for acceptance that pain was under-treated and also that the pain that was evident needed to be better treated. Most of these physicians were dedicated, compassionate, and hardworking individuals. The contemporary school of thought was that "pain medicine" was just giving opiates to people with pain but these specialists combined long-acting opiates, short-acting opiates, medium-acting opiates, anti-inflammatories, anti-depressants, anti-convulsants, and a variety of other medicines to treat pain. This was comparable to my Internal Medicine practice when I used to treat a Type I diabetic with several different types of insulin, multiple shots through the day, multiple sliding scales, and finely adjust their medications to control their blood glucose. These dedicated pain doctors were able to design regimens that helped control their patients' chronic pain all through the day. During this time the Joint Commission stated that pain should be another vital sign. There was no question that pain had been under-treated. We in the American Society of Addiction Medicine worked closely with the Pain Societies to try to propose policy guidelines. The Pain Societies then proposed that someone who had been an opiate addict could safely take opiates for pain if they were monitored closely with a contract providing for urine drug screens, single pharmacy use, and no early refills. They talked of an entity called "psuedoaddiction" which became accepted even though their was no medical research to suggest it even existed. The Pain Societies proposed that the gold standard for treatment with opiates should be that the patient's "function" improve. In other words, the patient should get out of bed and at least interact with their family if not go back to work. If their function decreased with the use of opiates, then the medication should be discontinued as they were functioning better without it.
During the time I was representing ASAM at the House of Delegates, the Pain Specialty groups brought a resolution on Oxycontin to the floor of the House of Delegates. There had begun to be a lot of abuse and also deaths related to Oxycontin. The Pain Societies brought forth a resolution that stated that the American Medical Association should make a public policy saying that the overdose deaths were being exaggerated and hyped by the media. At that time, we had had a lot of overdose deaths related to Oxycontin in Mississippi. I remember standing before the house and saying that I did not think it was a press problem but rather an Oxycontin problem. Most of those in the house seemed amazed when I stated that if a person was on 80mg Oxycontin, taking it b.i.d., they were taking the equivalent of over 950 Percocet or Tylox a day. I don't know why no one else had done the math. The AMA did not adopt this resolution but referred it for further study.
We all agreed that function should be improved if the risks of chronic opiates were to be accepted and if the function did not improve then patients shouldn't be on chronic opiates. Physicians are often codependent. We want our patients to like us and we want to relieve their complaints. I practiced critical care medicine for 12 years. Since I had an addicted father, I was very careful with my prescribing of opiates. I have, however, on more than one occasion, given someone a dozen Lorcet to get them out of my exam room so I could see the next patient. They had refused to leave until I gave them something for their pain. Most often, I did not feel that they required an opiate. I have talked to a lot of doctors who have done the same thing but it is the easy way out.
Most studies show that there is not a danger of addiction in the acute use of opiate medications for pain but more are coming out showing that there is a definite risk with chronic opiate use. I have treated and seen a lot of patients with chronic opiate use and pain as an addiction physician. Most of my patients have lost most of their ability to function as defined by the psychiatric meaning of a "Global Assessment of Function" or GAF before they get to treatment. They should have been taken off opiates long before and often people have tried. I have noticed that there are differences in how patients feel about opiates. There is certainly a class of people that would rather have some pain and be functional, and feel as though on opiates that they cannot perform at the level that they wish to. They are willing to tolerate the some pain. If you are one of the patients that are predisposed to addiction, however, and you are put on chronic opiates, your "pain" will never go away without the opiates, unless you are taken off and have treatment. In fact most have their pain increase (hyperalgesia). I have seen several thousand patients who came into treatment feeling that they could not live without their opiates become totally functional through two to three months of treatment. They run, they walk, they exercise, and they participate in the ropes course without the complaints of pain. Of course, there are many other medications that are good for pain. Research shows that all patients that have chronic pain should probably be on an anti-depressant as well as anti-inflammatory and possibly an anti-convulsant. When I listen to these addicted chronic pain patients when they come in, I hear one predominant story which goes along with what we know about about the physiology of addiction. Many of these patients started chronic opiates for legitimate medical reasons eg: a young person that has an automobile accident. Let's say that person has a family and a good job in addition to a social network. He goes through the required medical care, which may mean surgeries to fix bones and physical therapy. No matter how much insurance or disability he has, if he is out of work for two to three months, he will run into financial problems. He will lose contact to some degree with that social network. He goes home from the hospital and is on opiate pain medications and takes one when he is having pain. At some point in time, the genetically predisposed individual will develop anxiety, worry, and maybe even depression over the mounting bills, the complaints of his wife, the physical therapy and physical problems, job problems, and being home all day. He is worried about all of these things and at some point in time having pain, he takes an opiate. What he consciously or unconsciously sees is that the opiate not only relieves physical pain but it takes all of the worry over the problems surrounding his injuries away. If we fast-forward this over a period of time, the financial worries, job worries, relationship worries, and the physical problems get mixed in with the pain. He finds every time that he faces the stack of bills or the calls from his employer wanting to know when he is coming back to work that if he describes these as pain and takes the opiates all the worry goes away, even though the problems are not solved. Pretty soon, whenever he is having uncomfortable feelings, he complains of pain and takes the opiate, which relieves any physical pain plus the emotional pain. Over time, it takes more and more opiates to do this, which not only affects his recovery from his injuries but perhaps makes him more non-functional than he was previously. I don't think this happens to people who are not genetically predisposed to be addicted or it doesn't happen as often. I see these non predisposed people ceasing to take the opiates when they feel the opiates are making their function decrease. There are changes in the brain and spinal cord that occur with chronic pain and also with chronic opiate use. The patient begins to feel, again consciously or unconsciously, that they cannot function at all without the opiates. Somewhere down the road, their life is in the toilet and people around them have identified the etiology as being the opiates. Their doctors say that they should be doing better than this or they should be able to go back to work but they complain that they are in pain and cannot do so. There is a desire for most of us in treatment to use terms like legitimate vs. non-legitimate pain. I firmly believe that all of these patients are in legitimate pain. The big question is whether the chronic opiates are helping that pain and recovery process or hurting that recovery process. In the patient whose life and function have gone downhill with the use of opiates, a trial off of opiates is indicated. Many of those patients need to come to treatment to get off opiates and to get on alternative pain regimens. Remember, our gold standard for chronic opiate use for chronic pain is that the patients' functions improve. I've found that most physicians refuse to stand up to patients that are abusing opiates but simply try to discharge them from practice. We are in the age where generalists and specialists are going to be asked to intervene on alcohol and drug addiction and at least refer them for evaluation and possible treatment. I have run into a large population of people that refuse to take opiates because the drugs make them feel out of control. I think that that is one of the differences with people who are genetically predisposed. The opiates make them see themselves as more functional while the outside world sees them as having decreased function.
We have come to a time in our society and culture where we are going to have to change. We can no longer tolerate the overdose deaths and making chemical invalids out of young people with their whole lives ahead of them. It is always worthwhile if the chronic pain patient is not doing well on opiates, to take the time and energy to get them off of opiates for a long enough period of time to see if their function will improve. That requires an addiction treatment setting than can also objectively look at their medical problems.
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