Opiates

The epidemic of prescription opiate overdoses is a really complex issue. It's gotten a lot of press in the popular media especially as President Obama declared this a national crisis. But I'm afraid this is a much more nuanced issue than most people realize. There is no doubt that the number of emergency visits and accidental deaths from prescription opiates has skyrocketed. We are seeing less heroin, methamphetamines, and cocaine, and a lot more oxycodone and morphine. But the solution is not clear to me.

Recent guidelines strongly recommend avoiding opiate prescriptions outside of cancer pain and palliative care. In particular, there are recommendations to avoid long acting or slow release medications. Alternative pain medications including drugs normally considered for neuropathy, inflammation, and epilepsy are highly recommended. Indeed, I've read several recent research studies supporting de-escalation of opiates outside of cancer and the end-of-life.

These guidelines are quite reasonable, but for me, they highlight the difficulty in treating chronic pain. In anesthesia residency, we spend only a little time in the chronic pain clinic, but it is still more than family practitioners get. The few months I worked with pain patients taught me that treating pain is a highly specialized practice requiring advanced training. Of course, there are hardly enough pain specialists out there to care for the epidemic of chronic pain and its resultant epidemic of prescription opiates. But it does shine a light on the fact that complex patients should be referred to a pain practice.

I've met drug-seekers and malingerers, and I've also met patients with real chronic pain. In treating chronic pain, I believe (and have been taught) that long acting or slow release medications are crucial. They provide a foundation of effective pain relief in the same way that long acting insulin provides a background dose. Short acting medications help with spikes of pain in the same way that short acting insulin is given for meals or snacks. Avoiding long acting opiates can create big swings in pain management where the patient gets behind and then takes too much to catch up; it can disrupt sleep and impair function.

I definitely agree with multimodal management of pain, using non-opiate alternatives such as antiepileptic, antinflammatory, and neuropathic drugs. But in seeing patients on these complex regimens, I realize the risks of polypharmacy. It can be challenging for patients to keep track of their different medications or physicians to manage their side effects and interactions. When I read the geriatric literature, all of it suggests paring down on medications. How do we balance these conflicting recommendations?

I guess in the end, I chose not to be a pain specialist for a reason. But when I see the lay media, medical journals, and CDC recommendations on how to curb prescription drug abuse, I question how simple they make it sound. Like any other epidemic, tackling this is not easy. I hope that pain management physicians will step up to engage the public, educate physicians, and research ways of reducing overdoses and accidental deaths.