Chronic Pain Treatment Is Adversely Impacted by Opiate Phobia by David Bearman, M.D.

Introduction

Pain is a big health problem in the U.S. Getting adequate pain treatment is an even bigger problem. According to the National Center for Health Data, more than 60 million adults have persistent back pain, over 30 million have neck pain, and about that number suffer from headaches. Pain not only causes distress and decreases quality of life, but over a decade ago it resulted in 100 billion dollars a year in lost revenue. So pain is a health problem with economic consequences. The question is, what to do about it.

We seem to be practicing in a pain management environment hostile to doctors and patients alike. Like most issues related to psychoactive substances, our approach to dealing with opiate abuse has been influenced by focusing almost exclusively on the drug and not on the motivation for the substance use and abuse. This has led to the current round of opiate phobia and consequently undertreating pain.

• Is Over-prescribing the Driver of the Crisis?

Today's opiate phobia discourse puts major blame of the so-called opiate crisis on diversion of prescription opiate pain medication into the illicit market. This has lead to the conclusion that doctors are over-prescribing or inappropriately prescribing opiate medication and if we could stop that the problem of opiate use disorder would disappear or at least be less of an issue. This line of thinking has led some opinion leaders to claim that opiates should be reserved mainly or even solely for those who suffer with pain from cancer.

So has this effort to intimidate physicians from appropriately treating pain resulted in less opiate abuse? No. Has it made it more difficult for patients with severe pain to get adequate treatment? Yes. Patients with serious non-cancer pain, such as pain from failed back surgery, phantom limb pain, pancreatitis, severe arthritis, Crohn's disease, are more and more out of luck in getting effective pain treatment. While physicians are prescribing fewer opiates and there is therefore less diversion of prescription medications into the illicit market, this has had little to no effect on decreasing opiate abuse.

• Fentanyl

What we have seen is more and more Fentanyl smuggled in from China with more people dying from street concoctions containing Fentanyl. Fentanyl should either be taken off the market or if we must have it, than that pain medication could be reserved for use only in cancer patients.

I trust you agree that we should consider these chronic pain patients' quality of life in our policy equation. Most of us will have pain severe enough to seek medical treatment. Medical options should not be limited for unreasonable or irrelevant reasons.

How do we address those non-cancer patients who have serious chronic pain, if opiate pain medication is considered off limits for them?

Physicians Should Be Patient Advocates

Physicians need to be patient oriented. We need a balanced approach to pain management which considers patients with chronic pain in the policy equation plus a physician's Hippocratic duty to adequately treat their patients' medical problems, including pain. This as with the same caveat as with any category of medication. We don't want physicians creating undesirable iatrogenic problems. The vast majority of physicians are very cautious when it comes to treating pain.

Motivation and Intervention

So let's change our focus from the drug to the motivation for using the drug. Until we address the motivation for substance abuse we will continue to have ineffective drug policies and throw good money after bad. Substance abuse must be treated as a medical issue, not a moral or criminal justice matter. Most of us know and understand many of the motivations for abusing drugs. In my almost 50 years involved in providing professional assistance for drug abuse treatment and prevention, I've noticed that an inordinate percentage of these patients with substance abuse problems suffer from PTSD, often from growing up in dysfunctional homes.

As long ago as the early 70s, under the leadership of the late Superintendent of Santa Barbara County Schools, Lorenzo Del Armi, the County Schools Office spearheaded a program involving parents, teachers, students, counselors and school administrators with training farm experts and consultants in the psychology medical and education fields. It stood on three pillars: (1) teaching problem-solving/coping skills, (2) having students accept personal responsibility and (3) promoting self-esteem. These factors are critical in developing strong, happy, competent adults. Our schools, houses of worship and parents need all the assistance they can get in fostering these important tools for drug abuse prevention.

More of our governmental resources should be directed at early intervention and treatment and not so much on promulgating and enforcing laws that not only lead to inadequately treating chronic pain in patients suffering from severe pain but leave much to be desired in actually addressing the problem.

• Focus on Jobs, Family and Quality of Life

The bottom line is that substance abuse is a reflection of systemic change in the family, the community and the workplace. The popularity of anti-establishment politicians such as President Trump and Senator Sanders is symptomatic of a society in turmoil. This turmoil comes in part from changes in the economy, unequal distribution of wealth, a feeling of being overwhelmed by the complexities of modern society. We have an increasing number of unemployed and under-employed workers. This due to technology, outsourcing and other economically related changes. There are fewer jobs in tobacco farming, lumber, fishing, coal mining and car building industries. This fall off in plentiful good job opportunities, especially for unskilled workers, has led to many in society being burdened with hopelessness and helplessness. Until we address the causes of this underlying malaise we will continue to see substance abuse at what should be seen as unacceptable levels.

• Change Approach

We need to change our approach. We might look to Santa Fe, New Mexico and the experience of Angela “Spence” Pacheco, District Attorney. She saw firsthand that punishing people for drug use doesn't work. But innovative programs like LEAD that create alternatives to prosecution do.

She said, “I encountered a woman older than me who was addicted to heroin... We reached a point that we were required to impose mandatory prison time. I gave her the minimum sentence … I remember her apologizing to me because she felt she let me down. And I thought, 'There's something wrong here.' We've never been able to do anything but send folks to prison and that's not the answer.”

• Conclusion

When communities move away from arresting and booking people as a response to drug use and other low-level offenses, they can instead invest in steps that actually hep, like increased access to treatment case management, and other harm reduction services.

It is not that Santa Barbara does not have the resources or the interest, but we need to use our institutions of police, District Attorney, physicians, ER, probation, social service agencies, and mental health and schools to try approaches that move people from crime and destitution to competence and productive lives.

If we focus more on helping people lead quality lives we will not only impact opiate use disorder but physicians and pharmacists can go back to effectively and appropriately treating pain with all the tools in our armamentarium.