People in Pain: The Forgotten Victims of the Opioid Crisis

Who are the victims of the opioid crisis? Ask that question and people immediately think of the hundreds of people who are overdosing every day, some accidentally, some intentionally, leaving behind grieving families and friends. These are the tragic faces of this crisis.

Some people will talk about the millions of Americans living with addictions (of whom less than 1 in 10 is getting access to treatment), and their loved ones. Much of the conversation about addressing the crisis has focused on fixing addiction treatment.

But the most commonly overlooked victims of the crisis are the 50 million Americans living in pain -- who are not only not getting the support they need, but are in many respects forgotten in the rush to fix the other pieces of the opioid puzzle. Thanks to a focus on tightening access and a resulting climate of fear prevailing over physician prescribing, it has become difficult and in many cases impossible for people in pain who need opioids to get them.

One of the reasons I wrote The United States of Opioids: A Prescription for Liberating a Nation In Pain was to call attention to the full scope of the crisis and the need for solutions beyond increasing the supply of the overdose drug naloxone and medication assisted treatment for people who are addicted. The difference between opioids and other illegal drugs is that opioids have a uniquely powerful capacity based on the receptors in our neurons and nervous systems to relieve pain, which no other medication can match. Just ask anyone who depends on opioids for pain relief if ibuprofen or acetaminophen will do the trick for their pain.

Over the past 25 years of working with doctors, we have seen a pendulum shift on treating pain. In the 1990s and into the 2000s, the pressure was on physicians to make sure people in pain got the medication or other therapeutic intervention (physical therapy, chiropractic, etc.) they needed. We would see medical board disciplinary actions against doctors who were stingy with medication after patients complained. The focus in hospitals was on the then ubiquitous pain surveys, with pain treated as the "fifth vital sign."

Fast forward to the present and the pendulum has swung: around the country, tens of thousands of doctors are currently being investigated for overprescribing opioids. Here in California, the Medical Board and the California Department of Public Health are in the midst of an interagency review of death certificates for thousands of patients, cross-checking causes of death that were suggestive of possible overdoses (such as heart attacks) with medical records from doctors, hospitals, and coroners. The investigation is the broadest review physician prescribing in state history, encompassing more than two thousand cases to date and leading to disciplinary and, in some cases, criminal investigations against hundreds of physicians. Add DEA investigations to the mix, and doctors are living in a climate of fear. One pain medicine practice recounted that the only chronic pain patients they are still able to treat are those that have been on high doses of opioids (250 MMEs) that they are tolerating for over a decade, and only because these patients are absolutely unable to taper. When new patients show up, the maximum dosage that main pain doctors show up is only a third to a quarter because that's the threshold at which they avoid DEA and Medical Board scrutiny.

The tragic consequence is that people in need of care are being turned away, suspected of being drug-seekers. Where are people in pain supposed to turn? It's little wonder that so many are suffering, and others are turning to heroin, fentanyl, and illegal sources. It's not just the doctors and emergency rooms that are turning people away. If you talk to any patient who depends upon opioids to manage chronic pain, pharmacies have become the most recent barrier to to obtaining legitimate opioid pain medication. Many pharmacies are now protecting themselves by simply declining to fill any prescriptions for opioids. In other cases, pharmacies will not fill prescriptions until confirmation that the doctor has provided documentation of the prescription to the patient’s health plan. These hurdles, intended to prevent abuse, make the process of getting medications even more miserable for patients who are legitimately in need.

The long-term answer to this problem? We are living in a time of polarity, when the pendulum is still swinging to make opioids harder to access. We need to move back to the middle. Other than calling attention to the urgency of this shift, is there anything we can practically do?

 In the book, I highlight five things that we ought to be focusing on:

1. Developing condition-specific protocols for the use of opioid medications to create clear standards for doctors to prescribe to people in pain without fear of disciplinary or criminal charges: You might think that protocols have been disseminated for how doctors can safely prescribe opioids. The CDC came out with guidelines, but only for usage in primary care. We desperately need targeted and also simplified guidance for treatment for a whole host of different conditions, from prescribing for different kinds of pain--to liberate doctors from fear-based avoidance of pain treatment.
2. Demanding access and reimbursement parity: One recurrent challenge is the lack of alternatives pain treatment options. Even when clients find promising options, such as infusion therapies or neurofeedback, payor coverage guidelines often limit options by not covering forms of treatment. Reimbursement limitations also prevent physicians from extended discussions about non-pharmacologic options. One doctor I quote in the book commented that "[i]t takes 30 seconds to say yes [to meds], and 30 minutes to say no." There is a need for advocacy to enact mandates and expand access to non-opioid and non-pharmacologic treatment of pain. 2008 was the beginning of mental health parity. We need to make 2019 the beginning of pain medicine parity.
3. Increasing research on pain therapeutics: We desperately need to advance research on alternative pain therapeutics. Many federally-funded institutions with researchers interested in researching the potential of cannabinoids and other controlled substances are being obstructed from research by DEA refusal to reschedule cannabis under the Controlled Substances Act. We need to push for the removal of regulatory obstacles, insurance coverage mandates for new devices and therapeutics, and expanded funding expanded options to treat pain.
4. Expanding awareness of the problem: One of the central reasons for the lack of attention to the pain crisis (relative to overdose deaths and addiction) is a simple problem of lack of awareness. With 50 million adults in America suffering from chronic pain, we need to expand recognition and acknowledgement of pain and suffering in our communities and through workplace wellness programs. For a subset of the community in pain, there is a mind-body connection articulated by Dr. John Sarno, among others, that we are only beginning to understand clinically, meaning that some (not all) pain can be addressed through self-awareness and recognition.

For deeper insights into the opioid crisis and what you can do to help on America’s road to recovery, pick up a copy of The United States of Opioids: A Prescription for Liberating a Nation in Pain.

#notanotherstat #unitedstatesofopioids #chronicpain #paincrisis