The Unnecessarily Painful Treatment of Chronic Pain (8/6/12)
What’s Happening To Chronic Pain Patients?
Very difficult times. Federal and state governments have belatedly recognized there’s an epidemic of prescription medications – which includes pain pills like opiates. Influenced by that epidemic, some academic opinion on how to treat pain has also reversed. Many researchers who believed pain patients should be treated for maximum pain relief have back tracked. They feel too many patients are taking too many opiates, and are “hooked.”
The end result – lots of patients who have been on opiates for decades are now being pulled off their drugs.
What Are They Experiencing?
What I call “The Great Withdrawal.” Doctors are cutting medications – often quickly. Simultaneously states like Florida are restricting the number of pills different pharmacies can stock. So patients go from pharmacy to pharmacy trying to get their pills, and can’t find them. It’s a surefire way to create panic and increase distress. Some pharmacies tell them they will obtain their pain pills only if all their prescriptions are filled there – an interesting, blackmail approach to shoring up market share.
What Is Happening to the Patients?
Some are writhing in bed. Others have stopped working. Some don’t leave their rooms for days or weeks, while family members take on more responsibilities. Many just keep on and hope they can find combinations of pills that allow them to function. However, many of the now “more acceptable” opiates make little or no sense – if you want to fight addiction. Shifting people from oxycodone to dilaudid is the kind of change Matt Dillon’s character in “Drugstore Cowboy” would appreciate best.
Why Is This Happening Now?
Politics and money. The prescription pill problem was fed by companies like Purdue Pharma. They created a version of oxycodone that could be more readily absorbed – as well as quickly snorted. When the abuse potential was pointed out, they appeared to look the other way. Over the past decade chronic pain treatment also became increasingly lucrative for drug companies, device companies, and pain specialists.
Meanwhile the gigantic drug war has failed. Tens of billions spent on interdiction has produced bizarre, even grotesque results. U.S. cocaine prices are down. Mexico is now partially a narco-state with tens of thousands of drug murders and cartel operators openly buying religious shrines. American drug gang members help train hitmen and drug operators across Central and South America. Witnessing economies taken over by gangsters, it’s no surprise Uruguay wants to legalize marijuana sales – and rigorously control them through government stores.
Back here in the U.S., law enforcement knows it has a big problem with prescription as well as illegal drugs. They also know that “tough enforcement” wins media attention, votes, and greater funding – especially in tough economic times. So the fallout includes chronic pain patients writhing in beds.
Are Patients Near Death or Bedridden Getting Treatment?
Often, no. Recently a patient of mine described the saga of his mother. She suffered from severe, intractable pain and diabetes, among other chronic ailments. Unable to be taken care of at home, she spent years in nursing homes that refused to provide sufficient pain medications due to “regulatory issues.” When she screamed too much they shut the door. Unwilling to give her sufficient pain medication did not prevent them from attempting “tight” glucose control – and achieving frequent hypoglycemic reactions. Regular short acting insulin injections included one after she “forgot” to eat lunch. Her glucose plunged to 25. Soon after infection killed her.
Perhaps the scariest part of the story is that her son is an extremely intelligent physician-entrepreneur who tried to ameliorate the situation – and could not. Both expertise and money were in abundance – but unavailing. So imagine the situation where both money and understanding are scarce.
Why Is The Pain Problem So Difficult?
Doctors don’t undersand pain, and often don’t know how to properly treat it. Taught to look at “numbers” and “facts”, many pain patients show no clear laboratory or diagnostic findings. Conversely, people with horrible looking X-rays, MRIs and CAT scans complain of no pain – my grandmother was one. One size does not fit all – opiates are just one part of complex treatments. Truly comprehensive pain treatment, involving doctors, psychologists, nurses, physical therapists, physical trainers and others, is highly expensive. It’s also difficult to coordinate in our fragmented health care system. Add on the fact that people have vastly differing responses to opiates – drug detoxification by the liver can vary 20 fold from person to person – and that pain specialists and companies make their real bucks on procedures, and you get some idea of how crazy treatment can be.
Pain is an information issue. How the brain interprets sensory input is the main concern. However, unlike chemistry or physics, medicine has yet to see itself as part of information science – even though it likes numbers. Treating the numbers on a chart doesn’t help patients much if you are not measuring people’s subjective pain, nor measuring the inputs that truly explain their pain.
What Could Improve the Situation?
Convening a group like Britain’s National Institute for Clinical Effectiveness. They could study the problem and provide clinical guidelines that take into account pain syndromes, their immense clinical variety, and the cost-effectiveness of present treatments.
But that might happen if the American health care system was coordinated, concerned with both public health and public finances, and not mainly profit driven. So that’s not about to happen.
Health care should be about getting people healthy. When it does change its emphasis to health, some chronic pain patients might win a fighting chance – to get out of bed and back into the work force.
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