The United States spends over $90 billion dollars a year just to treat back pain. That's more money than the combined budgets of all our nations city and state law enforcement agencies.
6
I am a pain management specialist. This column contains so much misinformation that The Times should have been ashamed to have printed it.
First of all, there are essentially no studies demonstrating opioids are beneficial for chronic non-cancer pain. One of the reasons for the opioid epidemic is that doctors kept prescribing them despite this lack of evidence.
As to that reduction of opioid prescriptions by primary care physicians, it is worth noting that very few receive any education on pain management or the use of opioids. I don't know about other people, but I sure want doctors who know what they are doing. Unfortunately, many doctors say they are pain specialists because they could prescribe opioids. Studies have shown that they doctors scrutinized by the DEA and state medical boards are generally incompetent including many who exchange opioid prescription for money or sex.
Finally, it perpetuates the myth that opioids are always the optimal analgesics. In fact, for many of the most common forms of pain, the NSAIDs, anticonvulsants, and serotonin-norepinephrine reuptake inhibitors are far more effective than opioids as are many non-pharmacologic interventions.
15
@Steve
I don't get numb. Period. I've had 7 surgeries. Each time I have been put out during the surgery because I "felt it". I've had root canals while not yet numb. Pain medication rarely reduces my pain, and I dislike how it makes me feel.
Recently had some bone reconstruction in my upper jaw. After it, the doctor insisted that alternating higher doses of Advil and Tylenol would have the same effect as an opioid. I was skeptical, naturally.
In fact, it worked.
2
Pain is not a disease and opioids are no cure. There is no evidence (studies not anecdotes) in this libertarian Soros generated polemic. 150 die every day from opioids the overwhelming majority were hooked by their MDs who relied on corporate lies (not addictive, good for any pain)
Studies show these drugs are no more effective than Tylenol for non cancer pain.
90% used in US. You think “untreated pain” is a problem in the EU which has a real health system rather than a profit driven addiction generating machine?
6
@gramsci fan I'd like to see you get through recovery from knee or hip surgery with tylenol. You would change your tune right quick.
52
You are dead wrong.
Yes, some people need these meds.
But the data is overwhelming: the vast majority who get them do not need them. Chronic pain eventually breaks through these meds anyway. The best methods for long term care are learning to manage the pain with methods such as CBT (since the meds won’t work long term).
23
The best way to do something about this is to write to your State Medical Boards ... advocate for yourself as a patient and your prescribing pain physician... Show them this article. Show them the comments. show them the studies cited in the article. Email all the individual members of the board and the president. In Texas for example, the Medical Board reviewers are using 90 morphine milligram equivalents as standard of care which for many established legacy patients is well below where they have found stability.
These medical boards are intensively pressuring doctors throughout their state. They do it with expensive investigations, fines, license restrictions which make broad allegations about the doctor “non-therapeutically prescribing” and being a public threat to society.
50
Finally, some people in the medical community are getting a backbone and standing up to the opioidistas. Just because someone takes opioids for pain, he/she should not be made to suffer because someone else believes opioids are ‘bad’ for them. The worst was AG Beauregard Sessions. Now that a new Attorney General may be confirmed, a more enlightened attitude may prevail. Judge not lest you experience intractable pain.
89
Ms. Szalavitz's suggestion for "a safe legal harbor for high-dose prescribing for patients who truly need it — as well as for their doctors." is one good idea for the millions of us who fall through the cracks.
I'm very tired of being a guinea pig for the medical community because they're now, many for legitimate reasons, terrified of giving you an opiate painkiller in a quantity that works.
I had chronic pain issues that could be managed without opioids until the new conditions from my post Traumatic Brain Injury, following a near fatal meningitis and concurrent subdural haemorrhage, ratcheted it up.
They had me on morphine in the hospital and it worked. After 12 months of trying 14 different non-opioid medications, including the one that made me so dizzy I fell down the stairs and broke 6 bones in my foot, the third and fourth specialists at the hospital's out-patient pain clinic put me back on MS Contin about 10 years ago.
Six months ago I developed a new, excruciatingly painful auto-immune disease that my 75-90 mg/day sr-morphine couldn't manage. But since the guidelines here say no more than 100 mg/day of oral morphine they kept me in hospital for a month so they could wheel me over to the ER 4 times a day to get IV infusions of ketamine, otherwise I'd wake up screaming and disrupt half the ward.
To his credit my doctor has gone off-script with a fentanyl patch plus oral morphine to at least get me home with a care-giver for now. When that stops, so will I.
61
I feel for the doctors who prescribe opiates--they are stuck in a damned if you do, damned if ou don't situation. Treating an issue such as pain, which can not be reliably precisely quantified, is always going to have a degree of art. There will always be somecases of overtreatment and undertreatment. Compounding the issue are these bogus patient reviews of doctors online, etc. I feel pain for the pain specialists. Tough career choice.
28
Most people will never understand debilitating chronic pain and they are lucky. Chronic pain is beyond horrible. This knee jerk reaction to stem overdoses is a tradegy. Let’s look at the communities that often overdose: you will find disenfranchised communities who feel they have few economic prospects and feel left behind. They are looking for something to numb reality. We need to do some serious soul searching as a country. Doctors, please step up and educate our leaders. For those of us that live in the hell that is chronic pain opioids are essential.
82
Life is tricky, no?
3
Opioid abuse causes great harm, sometimes even death, to the persons abusing it. While I am sympathetic to their suffering, it must always be remembered that they voluntarily chose to abuse opioids. Therefore, while I support efforts to protect people from their own stupid choices to abuse opioids, I oppose any such efforts which inflict hardship upon persons legitimately using them to address pain caused by their medical condition.
For me, the choice is obvious and easy whenever the choice to be made is between someone suffering disease versus stupid people choosing to harm themselves.
35
This is exactly why I got on heroin. Usually only addicts use heroin once they find its cheaper and stronger then other opiates. I wasnt an addict yet I still risked going to jail to treat my pain. I suffered from chronic constant pain from a back condition and it was near impossible to find a Dr. willing to prescribe daily opiates. Now I handle my pain by going to a methadone clinic and faking I was an addict, which I probably am by now yet I also have chronic pain. One would think that Drs. could get there act together and discriminate between drug seeking addicts and people with genuine pain concerns. Yet the truth is that Drs. fear losing their liscence by prescribing to drug addicts vs. true pain sufferers like me which is unconscionable. America is so ass backwards on so many common sense issues causing so many people to needlessly suffer and it is usually based on fear or greed with politicians seeking only to score points.
115
Thank you for this article. I almost cried reading it. As someone who has been in pain my entire life I live in fear of having my medications taken away. I spent my childhood having surgeries, some useless or botched. The constant pain went from annoying to debilitating in my mid 20s and I went from needing pain meds a couple times per year to needing them daily to even partially function. There is clear evidence in my MRIs, CT scans, and surgical history to support why I am in progressively more pain. I have tried years of physical therapy, yoga, exercise, OTC meds, counseling and given up most activities I enjoy but none of that helped. With my meds I can sometimes be productive, volunteer, see friends-be a person. I can be an actual partner in my relationship. Yet I am judged by many people. They tell me I haven't tried hard enough, that I should accept my pain that makes me throw up and leaves me unable to sleep. I had to get to the point of being suicidal before my doctor realized how bad it was and stopped fighting me about the meds. Doctors destroyed my body in an attempt to make me lool normal, I believe they should be responsible for helping me manage the pain I have been left in as a result. While my doctor now is willing to preacribe my meds and we have a solid working relationship I can't move because the odds of finding a new doctor who would work with me are so low. I have been refused help from specialists for my serious conditions because I take opioids.
62
Indeed the needs of those in chronic pain are getting trampled in the chaotic effort to deal with the opiod crisis, but isnt this the result of no political leadership. The opioid crisis was declared an emergency, but no resources were made available to deal with the crisis on a federal level. Couldn't the CDC be put in charge, under an opioid czar who would force public discussion of the issues raised here and guidance to state and federal laws to gradually reform things. No one doubts that big pharma was much involved in starting and supporting the crisis, and the issues discussed here "lack of consideration for those in pain" were a major tactic for pushing irresponsible prescribing of opioids. On the other hand, this is not rocket science, and setting up a fair and impartial system to work out the issues should be possible. I would think that 20 thoughtful people in one room, given serious rule making and law enforcement clout, could resolve this in 10 years.
8
This is interesting. Twenty years ago pain was considered a serious problem and one that interfered with recovery (from surgery or whatever pain problem was involved). The advent of the pain scale came about at that time - you know, 1-10. Not a very good scale because some people have high pain thresholds and others low. Chronic, debilitating pain needs treatment as much as post surgical pain. The fear of addiction is driving a whole new set of problems. I have a friend who just had neck surgery, and he was given 5 tylenol with codeine and told to use ibuprofen for the remainder of his recovery. This fear of addiction has gone too far, and physicians are as reluctant to treat pain as they use to be eager to alleviate it. I was on oxycontin with fentanyl lollipops for several years for severe back pain. Once I finally had surgery, the need for the medication disappeared. I weaned off and have never looked back. Unfortunately, there are many people who don't have the advantage that I had, and they are suffering for no good reason.
40
Let’s be clear: Physicians were essentially mandated some years ago to treat pain as the “5th vital sign” (after heart rate, blood pressure, respiratory rate, and temperature), and were penalized for not treating fully all five.
Social engineering without frontline professional input is always ridiculous and dangerous.
29
@Stanley J. Oiseth, MD
Pain is serious and should be a focus of treatment. I was left in pain my entire childhood. After surgeries I was given only minimal support even when my bones had literally been cut and rotated. Months and months of agonizing pain but it was okay because I was a child. My parents were beside themselves but could not get me help. After a major back surgery the phamacy (the only one our insurance covered in our area) refused to fill my pain medication because kids don't need treatment for pain. Obviously doctors were and are undertreating pain. Not only is this physically damaging but mentally traumatizing. I still have nightmares and flashbacks to laying in the hospital crying and begging for hours to get some relief and having the nurses tell me to be quiet as my mom tried to get someone, anyone to come and help me.
57
Pain management is a very important part of clinical medical practice.
Pain management requires skills, empathy, resources, and time.
It is virtually impossible to manage pain with a five or ten minute or even half hour visit.
Rampant pharmaceutical advertising distorts pain management.
Pain management requires other modalities besides opioids. Opioids are vital in terminal cancer care and in acute circumstances such as trauma, surgery, etc. But not clearly elsewhere. They are also essential to thwart opioid withdrawal, but the very real price is opioid dependence not necessarily accompanied by genuine pain relief.
Our physician work force is degraded by debt, inflexible output measures,lack of training in pain management, and employer demands. There is inadequate pain management training and reimbursement
Yes, opioids can help in specific situations but the policy, institutional, and bedside skills are not there to make it happen.
In addition there is a need to enable every dependent patient on opioids, withdrawal management alternatives. We are even farther from that need.
19
Statistical evidence cannot be ignored. The US does prescribe way more opioids and our citizens die in greater numbers due to overdose contributing to a declining life expectancy. Doses associated with over 90 MME are more likely to kill. There is scant evidence that chronic pain responds well to opioids and there is good evidence that lowering its use can lead to greater comfort and function for many. The problem is that generalities such as 'more likely' or 'many' don't apply well to individuals.
And other individual factors also come in to play. I cared for a person who hobbled and moaned his way in and out of my office, only to be shown movies of his cavorting around a pool hall. There is no objective test for most pain. Some individuals are known to consume little to none of their prescription, a source of income instead. I can't 'examine for that'. And I am confident that the rising death rate is partly due to people resorting to heroin after being cut off their prescription. They, I assert, don't seek a 'high' but to manage their dependence. There is no test to discern who will and who won't.
This situation is very complex, and no one, not the CDC, the FDA, the DEA, big pharma, insurance, the doctors, or their patients have 'the true' answer. Compassion and anti-stigma is a must. Harm reduction must be next. And research for the future is an absolute need if this death by opioid pandemic is to be solved.
23
@David Greenspan
You could try believing your patients. I shouldn't have to "prove" my pain to a doctor or worry that one good day will be used to say I don't need pain meds for the 95% of the time I have more pain than most people can even contemplate. I would hate to be your patient.
51
@David Greenspan
Sir, I beg to differ with you...
Until You, walk in the shoes of a True Pain Patient ..Please understand these things you quote are untrue in our world..
33
Fortunately, there are several medications on the way, some of them pending FDA approval, that have been proven safe and without the addictive consequences of opioids. Many of these new medicines have been fast-tracked and should ease the problem in the near future.
8
While I sympathize with people with chronic addiction, it is a losing battle to try and save people from themselves. If an addict wants to get high they will find a way even if opioids are not available. Meanwhile, those in chronic pain who could benefit from opiods are left to suffer. Rather than putting restrictions on opioids there should be treatment on demand so that addicts who want help can get it
40
Most doctors follow trends created by their former practices.
The most intelligent essay on chronic pain & opioid medications I've seen in recent memory. It is difficult to stomach much of the commentary from individuals that lack direct personal experience with high levels of chronic pain. Pain is a highly subjective, highly variable neurological function. A chronic injury or pathology that I may experience as a crippling 8 or 9 on the 10 point scale could be experienced by the next individual as a mildly troubling 4 or 5. And other individuals, blessed with a relatively pain free life, may experience that same 4 to 5 as absolutely unendurable due to fatigue & frustration. There is nothing in medicine that is more abstract than somebody else's pain.
Most patients in long-term opioid pain management programs never misuse medications. Rigorous monitoring, drug tests, mandatory pill counts, etc confirm compliance with doctors' terms & conditions for continued program participation. The threat of discharge from treatment deters most legitimate patients from abusing medications.
Despite common perception, after the first days of treatment there is no euphoria with long-term opioid pain management. Our overdose epidemic largely results from the decision by a minority of patients to rapidly increase opioid consumption in an effort to repeat the euphoric experience of those first few days. This is impossible with a normal course of opioid prescriptions, pushing the abusers to supplement or replace their pain medications with street drugs.
62
A close family member is physically disabled and in chronic pain because of a previously undiagnosed genetic condition that made her susceptible to severe injuries when caring for patients as a hospice nurse. That genetic condition has caused her to have multiple failed surgeries to try to address the injuries, reduce her pain (and pain medicine), and increase her functionality so that she could have a better quality of life. The surgeries left her more limited snd in more pain and she was advised to take long acting opioids supplemented with PT and counseling and medication for depression about 10 years ago. She has had doctors cut her off out of fear and others reduce her dose which she naturally has developed a tolerance, too. She jumps through absurd hoops and lives in fear of being cut off. That is wrong. Comparing her circumstances to the addict who started with a few Vicodin after surgery or swiped pills is not meaningful. We do those with legitimate ling-term chronic pain issues a huge disservice. And, how many are veterans?
45
I'd like to have more sympathy for addicts, but when they're behavior impacts others lives so forcefully, it is difficult. First, it was Sudafed. Still having to sign for a pack for allergies. Then, opioids. I had shoulder surgery last year. It was intensely painful and all I could get from the doctor was tylenol with codiene. I asked for something more powerful and he said the DEA had been to see him twice already. I got 10 days worth. I was in agony for weeks. I was taking tylenol with ibuprofen about 4 times a day. So, for the 10% or so population that are addicts, the other 90% get to suffer. Prohibition doesn't work.
46
@Moira Rogow
Perhaps you are unaware that codeine is an opioid and that it is metabolized to its analgesic form which is morphine.
7
Legalize marijuana or at least "hemp" (CBD), and make surgery and physical therapy affordable so that when there is a treatment for the pain there's no obstacle to pursuing it. Offer better alternatives and the opioid problems will resolve themselves.
11
The government needs to legalize cannabis. It's not going to cure everyone's pain but it's a safe alternative. Since most medical workers are never taught the benefits of many strains of the plant, they don't know enough to prescribe it or it's illegal in their state. I've used cannabis for migraines for many years and am not addicted, nor have I suffered debilitating side effects. It's time to take the power away from pharmacy companies producing addictive medicine.
24
For me, this is a very important argument. My husband was in a near fatal car accident when he was in his 20s and broke his back. As he approached 60, the pain in his back was constant. The doctor prescribed two Vicodin a day and it has changed his life. He can participate in activities, go out with me, exercise. He is a happier person because he's no longer in a cage of constant anguish. I have my husband back.
My nephew, on the other hand, had very serious surgery. The doctor put him on Percocet for the post operative pain. There were complications and another surgery. All in all, he was taking Percocet for about 8 weeks, on and off.
He did not abuse it but the doctor panicked and just took him off the Percocet cold turkey and told him to take Advil, but my nephew was still in pain with an undiagnosed illness that the surgery had not cured. It was heartbreaking to see him. He'd just lie in a fetal position on the couch holding his abdomen and moaning. He finally wound up taking heroin because it was available and it became his pain management.
41
@Joanna Stelling We hear that there are no supportive studies for chronic opioids, under supervision and contract, that show that they help in chronic pain.
Yet, we have an example of how it does work, in the individual condition.
Perhaps rather than hoping for a doctor that only practices medicine based on controlled studies, we should hope to be blessed with one who takes the time to discuss these studies, and is willing to try, with a firm stop date, anything to see if it will help when nothing else has.
I'm still skeptical about cannibus, but do know from 35 years ago a friend having absolutely debilitating side effects from his Hodgkin's treatment, finding almost complete relief when he smoked for a day or two surrounding treatments.
Do we completely stop using them in chronic conditions? I know there are specialists who wish to stop the addiction by overusing. But in those situations where nothing else works, listen to anecdotal reports, and please don't tie the hands of caring physicians who really do want to alleviate chronic suffering by making it illegal to even try. That would be a crime in itself.
15
With some experience with opiates, I propose that there are two broad groups that respond differently to opiates on their first exposure. There are individuals who have post- operative pain, are prescribed opiates, and they get pain relief and then they go on with their life. The second group tend to experience the euphoria or “high”, even on their first exposure and then proceed to chase the high through the first prescription into illicit drug use, heroin use etc. I don’t know if the difference is physiologic or psychological, but there are individuals who become addicted at their first use and individuals who are never psychologically addicted, but somewhat physically dependent after decades of use.
The problem, to me, is that we treat both groups the same way. We conflate the pain patient who has been on the same dose for years with the illicit drug user who moves from licit to illegal drugs in search of the high. They are searching for relief from their perceived misery and they seek refuge in the heroin needle. There is no equivalency between the two groups and the federal government has no business treating both groups as criminals. Let’s stop the radical pendulum swims and settle on the fact that many chronic pain patients are being infantilized in service to the DEA. Please get the DEA out of my doctor patient relationship and stop threatening my doctor for acting in my best interest.
45
I've had several dental surgeries over the last decade. Until recently the dentist would prescribe three Percocet for the first three days after the surgery. I'd take one and have a good night's sleep, then toss the other two. For the last surgery he refused to supply a pain killer and told me I'd have to wait and see for it was painful when all the numbing agents wore off. If it was I could call and he'd prescribe a pill. So the pain hits at midnight after the pharmacies are closed. This is how people with no history of addiction are treated.
I also use an occasional Xanax for sleep, and for when I feel anxious during a bout of seasonal bronchitis which creates a sensation of not being able to breathe fully. I've done this for years, and never take the Xanax for two days running. Taking the occasional Xanax is better that taking steroids for the breathing, which, paradoxically, produce extreme anxiety and memory loss.
I used to get a prescription for 35 pills a year, and used maybe 20 to 25. The extras gave me a cushion so I didn't feel stressed about rationing pills. The old doc retired and the new doc will only allow me 20 pills a year because, she says, the government is monitoring all prescriptions for addictive drugs and she doesn't want to draw attentions to herself.
I understand that there are serious problems but this is nuts.
58
The problem with chronic opiate use is three-fold.
One is addiction. That may or may not be a problem for you, and its not what I want to point out anyways.
The real problems are tolerance - and what opiates due to testosterone. All opiates, with the exception maybe of buprenorphine) are LH antagonists, meaning they chemically castrate all men who take them daily. Leading not just to losses in libido and sex drive (again, you can argue who cares) but to loss in muscle mass (physical therapy now useless) energy level, and, drumroll, pain tolerance.
I’ve tested male Vets on chronic opiates who had a Testosterone of 60 - should be over 400. American Medicine seems to not get this, even though the studies have been around for decades. I can’t understand why. Bias against men? Who knows.
Also, our brain fights changes in pain sensitivity. It’s an atavism from the days our ancestors were chewed on by Tigers. If you try to numb that response, our brain fights back; for fear of not noticing the Tiger.
Between the low T and tolerance, chronic opiates actually make ppl MORE sensitive to pain, not less. Never mind the loss in muscle bulk that worsens things like chronic back pain.
The only reason people *think* it works is because of the initial great relief, and after that their brain has incorporated the opiates into its algorithm- so when you take them away its now much worse for weeks and weeks until the brain readjusts - by which time many have turned to the streets.
9
Thank you for your explanation.
2
Fyi, your comment stating that testosterone levels should be over 400--simply inaccurate.
Your comment re PT being "useless'. Simply inaccurate.
Yes, opiates can lower testosterone levels, typically to a mild or moderate extent, and generally not to the level which would negatively affect lean mass, according to available published experimental data. Your use of the term "castrate" is pure hyperbole.
Regarding your case of a testosterone of 60, this would be atypically low from opiates. I hope you properly evaluated for other causes. Statistical probability would suggest an altervative etiology.
18
@BostonDoc I would only consider this observation if the doc would have re-tested the testosterone after a period of his patients being off the medications.
4
Remember when one considered whether the "Cure Is Worse Than the Disease," versus what it is now and whether the cost of the cure is worse than the disease?
10
Let doctors prescribe whatever they think appropriate.
If people are fool enough to abuse opiods, let them. That's our policy for alcohol and tobacco, which have no medical use. Prescription opiods, with carefully controlled potency, rarely lead to accidental overdoses. They can put the black marketeers out of business.
37
I seem to recall NYT hammered away on opioids ad nauseam in past years and IMHO they share responsibility for some of this whiplash.
24
I have chronic headaches due to cervical spinal deterioration. I had surgery last year to correct the problems, fully aware that the success rate was 50/50. It worked somewhat (severity is lower), but I still need medication to be comfortable and productive - not opioids, thankfully, but muscle relaxers and Fioricet ( a mild sedative/pain reliever). My pain is nothing compared to others, but I cannot imagine life without the relief I get when I need help.
Keeping patients in chronic pain from the medications that make their pain tolerable is, in my opinion, as much of a crime as those using heroin or Fentanyl commit each time they inject, snort or otherwise ingest.
There will always be those who abuse anything, be it alcohol, tobacco, junk food or prescription drugs. Do not punish those who desperately need pain relief because of those who steal from medicine cabinets.
42
I think patients should be educated on all of the risks on long-term opiate usage and be able to make their own decision.
A small percentage of people get addicted after using opiates, but because we have so many people in our country, and so many people receiving them at some point in their lives, that it seems like a lot more people are having problems.
People might be getting addicted to prescription opiates, but it is unregulated opiates like black market fentanyl that is killing them.
Legalize and regulate!
16
@C
According to the CDC, approximately 25% of people prescribed opioids for chronic pain become addicted to them. Perhaps you consider this a small number but I doubt most people would
3
@Steve The CDC admitted that their data was *low quality* and mistakenly conflated illicit overdose deaths with legal prescription so they could declare an epidemic. Big money in epidemics. I believe somewhere to the tune of 6 Billion allocated to grants and other monies to secure the benefit of special interest addiction treatment agenda.
The real data is somewhere between 3-8% actually get addicted to their meds. So should we punish the others who have chronic illness?
19
Thank you for sharing! Pain patients have been ignored for far too long. I’m so grateful to see more and more media coverage!
33
My mother suffered from rheumatoid arthritis. Every bone in her body was impacted, she screamed in pain, and before her death, her spine collapsed. Forty years of awful suffering. Gratefully she had a doctor who gave as much pain medicine as she could handle-and she still was in pain. She often siad if she were a dog someone could put her out of her misery. And even if she became an addict....so what. Let's have some compassion for those with chronic pain, stop the doctors who prescribe to people they know are "using." and don't hold back what modern science can give to those who need it.
42
Thank you for publishing a contrary article on chronic pain and the responsible use of opiate pain meds.
There is too much hype and hysteria around this topic, and unless you have experienced or are experiencing chronic pain, your opinion is just that, an opinion. Unfortunately the CDC is at the center of the hysteria.
Drug abuse is definitely a serious issue, but please note that there is a difference between addiction and dependency.
The ultimate decision around pain medication should be between patient and physician.
37
@Bill
You are absolutely correct! Dependance does not equal addiction!
I've never missed a pill count, drug test, even after acute pancreatitis I wouldn't take any extra or other pain meds.
My pain contract equaled life to me. I could work. Without these medications my life is reduced to nothing.
I have 2 options. I can end the pain permanently...or I can throw my education, RN degree, and everything I've ever worked for away...and go to the streets for relief.
40
I am a chronic pain patient with arachnoiditis ( nerve clumping) in my lumbar spine and neuropathy from my cervical spine..the chronic pain does bring many pain patients to the edge of suicide. Forcing us to take less or even stop the opioids we need to get off that edge is unreal. I see comments from people who are not in pain, why comment? You have no idea what it's like..how it feels..what we have lost from this pain. All of us have had to try all non-opioid treatments for me none of them helped... including CBD and cannabis. There is not one treatment I haven't tried up to and including surgery, spinal injections, spinal cord stimulation, physical/massage therapy, acupuncture What's left? Now I have been reduced and I will run out early..what are my choices? Hope for some help from a doctor? Or am I going to be pushed to the streets as many other pain patients..or will I be forced to take my leave? Do we, as chronic pain patients, need to stage our own Jim Jones out for some kind of recognition for the ones we leave behind? These are our thoughts..this is our reality...those who don't suffer have no idea ..and those who don't suffer should not be making laws which have no empathy for us. Our treatment should be between ourselves and our doctor. Why haven't they come down on alcohol? Alcohol kills plenty more people than opioids, and destroys families, stresses the healthcare system, yet nobody's has come after alcoholics or the makers of alcohol.. Why hurt us?
41
@val
I know where you are. Exactly. I've had everything done too. Injections, ablations, stimulation, chiropractors, alternative treatments etc. It takes a hell of a lot of money and does almost nothing. I BEGGED for an internal pain pump...anything that would stop the pain. I'm too young for new knees, and they don't give out new spines.
These keyboard warriors and legislators should have to spend a week in our shoes. See how long it takes them to want to exit stage left. I dont want to leave my family...but I cannot live like this.
People care more for dogs in pain than they do those of us who suffer.
What is being said loud and clear is...we dont care...we dont believe you...you are worth less than a dog/pet.
31
Another article filled with anecdotal stories about people suffering from chronic pain.
What we need to be doing is figuring out why, as a country, we are 5% of the worlds population but use 80% of the worlds opiod medication.
Then we can have a serious discussion of how to deal with this crisis.
5
@richard g maybe many other countries have many more people suffering from terrible pain and not being treated for it.
There is a problem in this country, but those who genuinely need help should NOT be punished because of those who abuse.
28
The summary: "doctors are cutting pain medication - and sometimes leaving patients to suffer" is irresponsible. The practice of medicine has been increasingly dictated by all of the usual suspects listed if readers take the time to read the whole piece. Demonizing doctors at the top ignores the reality that doctors are in the middle. The practice of medicine today is an endless accounting to government and large insurers. It is endless clicks to record accountability.
16
@Lauren: The guidelines are clearly stated to be guidelines. Being a patient, I rapidly came to realize that the effort to justify a higher dose than the 90 mg of morphine equivalent a day is more than our physicians (shame on them for not being willing to do the paper work) are willing to undertake. However, we, the patients have little alternative to the physicians who practice in this field.
17
An acquaintance of mine has been taking an opioid for over 12 years to treat his intractable shoulder pain; he holds a responsible job, and he shows no signs of addiction. Up until a year ago, his physician, during his semiannual check up, would give him a six month prescription for his pain medication; however, five months ago, his physician indicated that he would only prescribe a 30 day supply and that he would have to schedule an office visit every month to have his prescription renewed. There are many possibilities as to the reason his doctor decided to make this sudden change in his prescribing regimen, but one can't help but wonder if it has anything to do with the doctor's income.
10
@Mathman314
Six months pf pain medication dispensed at once would have several tens of thousands of dollars of street value. It would be irresponsible of any provider to prescribe that much at once.
5
@Mathman314
It’s the government rules, not the docs.
13
@Jen
That’s a one month supply with five refills. Used to be standard since it can be difficult for anyone to get time off to go to MD every month and not always easy to get in to see your MD what with job, kids, carpool. Nobody is asking for 180 day supply - just the opportunity to not be treated like an incompetent child.
5
cannabis.
it isn't a miracle drug ... it can't cure cancer or acne.
but it should be given a shot at everything else.
especially at the highly subjective and multifarious affliction known as "pain".
4
the high visibility opioid epidemic presents problems we are unwilling or unable to cope with. though hardly an expert, even I can see a small % of pain patients, perhaps also with other issues, wind up addicted. lots of people, perhaps without debilitating physical pain, become addicted to opiods. why? seems to me this group has two categories: a smaller coterie of thrill seekers who foolishly figure addiction can't happen to them, and people who are self-medicating to treat emotional pain. and that seems to be the main problem: undiagnosed or untreated, neglected psychic pain that we just don't address. somehow, the notion that people ought to suffer because that is what life is about before we go to heaven and the strong buck up and bear it while the weak fall victim is something out of Calvin or Bosch. as long as we hold fast to this losing proposition, there will be no end to the crisis of addiction, no matter how we try to feel better about it by forcing those in pain to endure suffering. look wherenthe problem is, not at what seems to be a fast and easy solution.
10
no perfect answer
2
The laws of 1) unintended consequences; 2) no good deed goes unpunished; and 3) the only tool (you think) you have to work with is a hammer, are working hand in hand here.
In the first, don't confuse "unintended" with "unpredictable," when the rise of opioid deaths from the use of street stuff as a consequence of sudden or tapering to zero cessation of availability of opioids is entirely to be expected. There is NO guarantee of dosage, quality or even if a street "pharmacist" even truly knows what really is in the package he's selling. If the drug doesn't kill you, the pain can easily make the pulling of a trigger or the leap off a rooftop or a bridge an option of serious consideration.
The second and third laws have their roots in the overwhelming influence of the concept of sin as the basis of laws intended to control behavior, i.e. the moral bankruptcy that is the religious concept of addiction, regardless of whether it be sex or drugs. Thus, the good deed of involuntary, forced abstinence, with the (totally unfounded) belief that the sinner will just naturally "see the light" as the body returns to a drug-free state. The goal of which is, it is easy to assume, is to make an addict's life here on earth hell (the religious hammer), until such time as that person dies and goes, obviously, to the eternal hell he or she deserves.
And then, there is Portugal. But how can a small, inconsequential European nation have anything to teach America about handling opiates?
12
When we we learn that prohibition doesn't work. We have empirical evidence from alcohol, cannabis, cocaine, and now opioids. In fact, the crime that prohibition creates, since the law of supply and demand still functions have created an opening for Mr. Trump to further demonize immigrants seeking a better life.
13
I agree with this article. But I think the Senate and House pulled this stunt to save Medicare in my opinion. The Insurance industry is lobbying hard to get out of paying for any pain relief. After the 90 MME chart came out from Andrew Kolondy who was an addiction doctor whos own patients wete funning around high while investigators were onsite at Pheonix House insurances had a record year. Andrew isnt a scientist and did NOT belong at the CDC. Many of the people shoved into Government positions dont belong there but donors and friends of politicians know more about screwing the public than doing their jobs. They dont even want to allow enough bupenorphrine or Methadone to treat pain. My doctor is 10 milligrams over because of my pain and my insurance Cigna is sending him nasty letters. I've been taking my meds for 10 years now. I had my doc put me on Methadone for my pain after the relief from Oxy would wear off every few months. Yet everyone has a stigma about it. Your heart has to be in good shape to take it though. Let them use the addiction meds for pain and stop trying to force us through addiction clinics. And frankly I also believe somewhere in this ugliness some people are invested in addiction clinics as well. I would like to see the money trail from Opiate pill, Addiction medication, Insurance, CDC, Congress, Underwriters Insurance, Opiate Committees to Addiction Clinics and know exactly who owns what. Quit threatening doctors as well.
11
People die every day. Some before being born.Most from living. Some “naturally.”After a longer or shorter life; of wellbeing,or not.Some directly from their diseases.Some because of indirect consequences of a condition/ disease. Some, like children who just don’t wake up, we do not understand why. Some from outcomes of states of BEing. Poverty.Conflict.War. Death rates differ in the divided US by states. Starving to death in Yemen. Some suddenly shot in planned mass murders. Some drowning on foreign shores. Escaping from….Rejected by… Some dismembered.All sorts of deaths.Drug cartel-related ones; Mexico as an example. Some from torture. Some people are “disappeared.” More than 250,000 people die in the United States annually because of medical mistakes; the third leading cause of death after heart disease and cancer. Some die by their work: tree-feller, at a risk of 357 deaths per 100,000 people a year; firefighters at a risk of 10.6 deaths/ per 100,000 people a year; being a truck driver, with 44.8 deaths per 100,000 people per year. The media reported big-killer is opioid ODs. Reported just about every day. Addicting drugs KILL? An addicting word.Term.Concept.Process.Outcome. Not people’s choices.Judgments.Decisions.Learned from or not. Better to maintain pain and make chemical-killer ADDICTORS unavailable. [Not the 60,000 inadequately regulated environmental toxins].MDs knowingly treat. Many heal. What law effectively treats or heals? Unaccountable policymakers live long.
2
Another fine example of a lack of common sense, that defies logic and reason, a total failure by the CDC to take a full comprehensive look at the situation and its impact on all patients. These guidelines were more akin to a knee jerk response to the opoid crisis than thoughtful, insightful recommendations that were needed. Doctors have become lambs leaving patients to "heal themselves" which seems to be kill yourself if you can no longer endure the pain. After all - law suits rule! Our medical profession has been overprescribed by the insurance industry, ill thought out medical guidelines, misleading business practices that encourage doctors to prescribe certain medications over others, and an industry that still doesn't empower a patient to be an advocate or a true participant in their own care. The patient is a helpless bystander, suffering, while having to deal with an onslaught of heinous actions by an industry at a time when they, the patient, is at their most vulnerable. Time for a major overhaul of this system. Unfortunately, we also have a dysfunctional government that doesn't care a whit about the American people, let alone its most vulnerable.
77
@Kathryn Meyer
You make it sound like the CDC guidelines are new or different than what has been previously recommended and are only in response to current concerns about opioids.
I have been a pain management physician for over 30 years and the CDC recommendations are nothing new but simply again state the recommendations made by virtually every professional organization during that time.
Where are the calls for prescriptive medical marijuana to treat pain? Pharma is against such and politicians and many (most?) doctors follow their lead.
Also, I see that Trump approved a bill deregulating hemp so that medical research can and should move with haste regarding hemp properties and our Endocannabinoid System (ECS).
I have only read some 25 or so comments here but am struck that opioids are discussed as if they provide the only avenue for pain relief.
3
@MaureenM for many of us Opioids are the only relief...I have severe chronic pain and there is no cure, nor will there be in my lifetime..I have tried multiple times different CBD oil and marijuana ...I had no pain relief. So hemp research and all the other non-opioid treatments might work for some but not for all of us..we shouldn't be pushed to the edge while others who are not in our pain make decisions from their healthy bodies.
13
The assumption that patients in chronic severe pain need to suck it up and buy more Tylenol is one of the most cruel and misguided adventures we have seen in medicine. All this effort to punish patients with legitimate need for opioids leads to despair and unnecessary suffering. It's actually pretty easy to identify the pill pushing pain clinics out there and focus efforts to put them out of business. Most legitimate pain patients and their physicians are responsibly trying to find solutions to chronic intractable pain and our one size fits all solution is nothing short of cruel. SHAME ON US.
156
@BA the assumption is cruel and utterly wrong. Spreading rumors and falsehoods harms your cause. As a matter of fact chronic pain is treated better than ever, with a variety of measures that optimizes the utility of narcotics. It’s one of the biggest challenges in modern medicine but one that is addressed with the best evidence available. And again an anecdote is worthless in most cases, it’s an unsubstantiated claim typically used when the evidence is unfavorable to the argument made.
@Oliver Herfort, after 3 years of successfully controlling my now 95 year old, house bound father’s pain with Fentenyl patches, his doctor resigned from being his physician because of the new draconian laws that went into effect in the spring of 2018.
In order for another physician to become his doctor he had to switch to Percocet...which we did, until that became to difficult to prescribe, and that doctor dropped him as well, because she was getting hammered by the state for prescribing it.
We moved to another visiting doctor practice and they prescribed slow release morphine. He ended up in the hospital because he was not metabolizing the medication properly and it almost did him in.
The doctor in the hospital told me he should be on Fentanyl patches! Seriously, I thought I was going to scream right then & there.
Now he is taking oxycodone, but the visiting doctor practice is closing. Luckily the nurse practicioner who was charged with his care found another agency to work with, but she must see him in person each month before she can prescribe his pain meds.
The entire thing is outrageous! We have a 95 year old, who fought for his country in the USMC during WWII, paid his taxes, raised 4 daughters, buried his wife and this is how he is being treated? It’s an abomination.
57
The medical business gives millions to politicians, and gets billions, if not trillions, in return. This, not only harms patients financially, but also harms many patients, such as those denied the best treatment for their pain. The political power of the medical business is harming patients' health.
12
It is sad that so many chronic pain patients are now addicted to their opioids. The fact of the matter is however that opioids are ineffective in the treatment of chronic pain, are highly addictive and easily diverted. The overprescribing of Opioids has devastated this Nation, destroyed countless lives and communities, killed hundreds of thousands of people, lowered our nations productivity and life expectancy and played a significant role in putting a demagogue in the White House. What we were taught back in Medical School Pharmacology prior to the misinformation blitz perpetrated by Purdue Pharma remains true: sustained release oral opioids should be reserved for pain management in terminal cancer and for hospice care.
7
@thewiseking The devastation and destruction are caused by black market opiods, not prescription opiods. With prescription opiods people function well for decades with minimal risk of overdose (unlike alcohol which destroys lives and tobacco which ends them).
15
@thewiseking
We arent addicted. We are dependent. Two very different things.
I have chronic pain therefore I am dependent on my pain medication.
I also have diabetes...I am dependent on my insulin.
Heart patients are dependent on their heart medication.
The ignorance comes with not knowing the difference.
17
@Kristie, addiction and dependent are the same exact thing. The term "dependency" is specifically used with addictive drugs for a reason. Dependency has a lower stigma attached to it.
1
Blame the government, blame the doctors, blame the drug companies. But let’s not blame the broader general public! Doctors started more freely prescribe pain medication in response to demands by patients to treat their pain. Who has not gotten a survey after seeing their provider to rate how well they were cared for and whether their pain was treated ‘adequately’? Health care administrators, many who never had interaction with ill people outside their own family, have made financial decisions regarding those providers base do on those surveys, and if they see customers are unhappy with the services received, no matter the medical outcome, those providers get financially dinged. So, let’s place a lot of the blame where it belongs, on the general public which has driven this desire to not have any pain.
3
The truth: The number of people needing opioids for chronic pain is dwarfed by the deaths and human damage of opioid over-prescription in the United States.
Nearly 50,000 deaths in 2017 due to opioids, more than traffic deaths, more than total suicides.
Using anecdotal stories of chronic pain vastly underplays the horrific opioid epidemic that has been unleashed on the US unlike any other country in the world.
Ms. Szalavitz is selling addiction to a nation that is just now trying to wean itself from Big Pharma's determined, profit-driven grip.
Also, addiction can be beat. It is not a perpetual state to be nurtured in perpetuity by methadone. The brain is fluid and can be retrained. Sciene has proven it so. But addiction "experts" would lose funding by following the science.
4
@JohnBarleycorn
I must respectfully disagree with you. The estimated rates of addiction vary widely, but even the highest estimates show addiction (not physiologic dependence) occurs in a minority of patients. Most researchers put the rates of de novo addiction somewhere around 5%. The CDC concurs. The highest estimates come from studies cited in a review article by Juurlink and Dhalla who report that “dependence and addiction …. in up to one third of patients in some series". These numbers include both dependence AND addiction. Rather than only referring to physiologic dependence, the term dependence has become an increasingly nebulous phenomenon in recent years with the emergence of terms like complicated dependence (inability to taper without the presence of bonafide addiction) and some researchers opting to use the term dependence as an umbrella for addiction and complicated dependence believing it’s less stigmatizing. Even if you opt to accept this highest estimate of 33%, that still leaves 66% percent of patients who did not develop addiction or experience complicated dependence. Due to space limitations, my references appear in a separate reply to your comment.
10
@Anne Fuqua
Thank you. Thank you. Thank you!
These people speak in ignorance. It is infuriating.
Yes there are a lot of deaths due to opioids. 95% of those deaths are from illegally manufactured and illegally sold opioids...not from actual pain management patients.
We are being made to pay the price for their addiction and lifestyle choices. Its abuse and cruelty.
7
@Kristie
YW Kristi:). Some people just don't get it. People don't understand what they haven't lived and too many lack the empathy needed to respond appropriately to things they've been fortunate enough not to experience personally.
8
The narcotic numbers for sick patients are combined with illegal substances and presented as total numbers of those who are 'abusing opioids' When people have chronic pain disease they need pain medication. A friend of mine can't walk or drive because of her pain--the pain clinic is using cherry juice to 'treat' her. It's not working. She's now on medical leave because of the intractable pain. We chronic pain patients are being treated like criminals when pick up our pain medication (or ask for it). Somebody needs to write an article on the DEA, FDA, and CDC and expose the lies. We are not addicts. We are patients. (I am disabled, but who cares?)
20
Szalavitz offers sane and sage recommendations for addressing the twinned problems of pain management and drug dependence: knowledgeable, compassionate, and non-judgmental treatment for patients. We need to get rid of both our one-size-fits-all approach to medicine and medical professionals need to stop thinking of themselves as arbiters of morality.
7
Thank you for this piece.
I have known chronic pain intimately, both from my own childhood and from having seen it up close among loved ones. This country has long ignored or otherwise utterly mistreated those who suffer chronic and debilitating pain. The quality of life, with chronic physical pain, is shabby indeed. Let those who truly need opioids have full access to them. At the same time, I am hoping that something good can come of greater acceptance of and experimentation with some of the extracts from cannabis and other non-opioid sources.
15
No general rule can contain the widespread abuse of opioids and anxiety drugs. While there are legitimate uses for these drugs, their misuse is all too evident. There is an urgent need to control the marketing strategies of drug companies, the tactics of drug representatives, and the doctors who overprescribe them, while ensuring that patients with legitimate needs get help.
3
88000 people die every year in the USA of alcohol related deaths.
A large percentage of drug overdoses each year are not related to opioids.
Many folks that use illegal opioids use it for its antidepressant effects. They have no access to healthcare or are afraid to admit they are anxious or depressed in our perfectionist society.
16
Doctors have gotten very little blame for the opioid crisis. In my opinion they are more to blame than the pharmaceutical companies. They accepted money, gifts, travel and prescribed never ending drugs to a vulnerable population. What happened to clinical judgement? Same goes for patients who truly need these drugs to get by.....why are not our highly educated doctors standing up for them?
3
As usual, the pendulum has swung too far into the opposite direction defying logic and reason which leaves people who really need pain medication without remedies.
I hope there is an effort to have thoughtful and safe prescriptive practices that alleviate suffering while not encouraging addiction.
Right now it seems the baby is being thrown out with the bath water- to use an old expression.
18
Valid points on a very difficult and complex situation, the inadequate attention in providing relief of pain and suffering...by withholding available effective medication. And if we are having pain, opioids do really help. But the over-prescribing, many times out of self-service, or laziness, or whatever, will likely lead to it's abuse and dependence (addiction). This, independent of the huge problem of illicit drug use and overdose morbidity and mortality, another chapter ever nore frequent in an over-worked society, where chronic fatigue and unresolved stress, seeking relief in all the wrong places. As to what qualifies as being 'cruel and senseless', is yet another unresolved issue we need to find an answer for. And not feeling as compassionate about something we haven't experienced (yet) may be part of the problem.
2
Drugs are cheap. Insurance companies limit or do not cover alternative pain modalities. Few can afford continuous alternative treatment of chiropractor, physical therapy, acupuncturist, shiatsu massage, etc. The energy put into the outrage against Oxy, Purdue and Sackler would be better used make sure that individual pain management treatment that includes alternative pain therapy is available to all who need it.
My heart breaks for those in chronic pain that have had your only source of pain medication relief that works for you reduced or taken away. Suicide and suicidal thoughts from living(?) in hopeless chronic pain because this country mismanages the treatment of pain. Individual pain treatment plans are needed but it all comes down to who will pay for it. Where is the outrage against the insurance companies who will only pay to drug us?
As a NYC school teacher, 6 adult sized sixth graders slammed a door into my head for fun. My UFT insurance had a limit on chiropractic visits and provided no other alternative pain management treatment. I used up my discretionary funds and had to discontinue alternative pain management. I lived(?) in unmanaged pain for a few hopeless years. Fortunately, my neighborhood chiropractor offered me sliding scale so that I could come often enough for effective treatment.
The majority of us are for Medicare for All. Medicare for All must include individual alternative pain management. Let’s put our energy into passing this.
6
@Calico, yes on all counts, and I'd add that "alternative" therapies for health problems beyond pain should be covered.
An ACA draft at one point (widely discussed in Trad'l Chinese Med circles) included a provision for coverage of all licensed health practitioners, which would have included, at minimum, naturopaths and TCM practitioners. It was scrubbed later, probably due to the fact that the primary author was a former health insurance corporate exec on Baucus's staff. Another "licensed practitioner" provision is what is needed.
Cost? More in the short term, big savings in the long term -- and that doesn't even consider the reduction in suffering it would bring.
2
@Calico, and of course chiros are licensed too, so would be covered under a "licensed practitioner" provision.
I'd add that when I was an AK resident, two prominent Republican politicians had their late-stage cardiovascular disease righted by an "alternative" practitioner using "alternative" methods, and a provision was then passed in state law to require that health insurance sold in the state had to cover all licensed practitioners on the same basis.
Unfortunately, the primary (and effectively only) insurance available in the state was Blue X of WA and AK, and a subsequent court ruling found that since BX applied also to WA, the provision was unenforceable ... and it was quietly repealed.
1
@Calico The root of this patient's problem was physical aggression by adult-sized 6th graders. Those "kids" should have been in a special school where their behavior could be controlled, both because of their violence and because of the intellectual deficiency that had kept them back several years. What happens to normal 6-graders in such a classroom?
It's the NYC public schools, where no one cares.
2
Many opioid-prescribers don't want to reduce or discontinue their pain patients' opioids.
But they're being forced to by their malpractice insurers and the owners of the clinics they work for, who may not have any medical training but are very good at focusing on the bottom line.
Ever wonder why physicians seem to rush patients through their appointments? Their employers have put them on a tight schedule: See X number of patients per hour every day or be penalized. Doctors who dare to write opioid prescriptions often face increased scrutiny and financial penalties from the companies that pay their salaries -- malpractice insurers will raise their rates for that transgression.
Pain patients are often difficult to treat. Business managers may encourage physicians to "fire" them or otherwise discourage those with complex, time-consuming health issues from returning to the office.
American medicine has little to no concern for patient suffering; it's all about the profits and keeping costs down. Don't get angry at your doctor. The fault is in our "stars": the accountants, lawyers and MBAs who see humans as profit-generators instead of people.
11
Seems like the sane approach would be somewhere between (a) prescribing 72 oxys for routine, outpatient knee surgery (as the clinic where my wife had the surgery did; she was fine with a few otc painkillers) and (b) cutting off pain meds to people who actually need them for debilitating conditions.
But when has the conventional medical profession been accused of sanity?
8
The withholding of pain medication is not new. About 6 or 7 years ago was visiting mother in Chicago and had a bad case of sciatica. Tried walk-in clinics, but could not find a doctor at one who would examine me and renew my Rx for vicodin. Everyone said: you are not my patient.
4
I know the analogy may seem strange but as I was reading this article, I thought about the abortion debate. Why? Because it is someone outside the doctor/patient relationship trying to control treatment. In one case the CDC and the other state governments through the courts. I suppose that the opioid problem is worse because doctors were sold a bill of goods about the efficacy of opioids a long time ago by the very drug company who made millions off the sale of the drugs. But getting between a doctor and the patient leads to wrongheaded decisions that affect a great many people-those with chronic pain and those who want abortions to be safe, legal and rare.
17
I’ve had that kind of pain before. It is relentless. And yes, suicide seems to be the only answer when it is at its worst.
17
What is wrong with our society?
Is there no understanding of patients with chronic pain who live their lives dependent on medical professionals prescribing appropriately opioids for relief?
But there is sympathy for drug addicts on heroin illegally obtained on the street who overdose on fentanyl and die?
It is reckless and shameful that "officials with the Centers for Disease Control admit that they do not specifically track suicides by patients who have lost medical access to pain relievers, so we don’t really know how many people are killing themselves because they can’t live with their pain."
Who is running the CDC?
28
@Mimi yes this is all about saving them..even though in most places they can get methadone a drug just as strong or stronger to keep them off heroin .
3
When heroin or another addictive drug is administered to someone in pain, they don't get addicted. The trick is to get them off when the pain subsides, and this is the doctors' job.
Doctors should be educated, and failing that penalized. Doctors who abuse their prescription privilege should be suspended. It is initially the doctors' responsibility, and only after addiction does it become the patients problem.
5
@Baddy Khan It's first and foremost the responsibility of the PATIENTS to understand the potential for opioid addiction and monitor their own consumption.
It's simple to understand that if I become addicted to opioids the prescribing doctor and manufacturer won't go through withdrawal when my supply is cut off. I'm the only one who will suffer.
Big Pharma's job is to provide drugs and educate consumers about the side effects. It is NOT their job to monitor end users for misuse and outright stupidity.
4
Maia thank you for another well written piece of truth!
I am so glad to see many people who are not pain patients showing compassion! Six months ago if this would have been written, the comments would have been mostly hateful and lacking compassion for those of us that suffer 24/7. That alone has caused so many to give up; few people realize the power of their words when sharing their opinion.
I am a patient like those mentioned above. I have lost my home, my family is in shambles, my two special needs foster children were forced back to live with their mother, I no longer am able to work even part time, and financially we are ruined.
10 months after my forced taper began, my health has declined further than it did in 10 years through 2 cancer battles. In an attempt to taper my 2 pain medications, I now take 7 other medications (some 3 times a day) for side effects of ‘safer’ drugs and damage done by relying on NSAIDs. How is that helping anyone? How has that done anything but destroyed 6 lives in my immediate family, USA lost tax payer & now pays SSI, husband works 2 jobs, and I could go on!
How did that save even one person?
The worst part about everything is the lack of compassion now seen by those who used to hate seeing anyone suffer. The narrative today reads that someone with high impact intractable pain must be lazy and addicted, yet all we want is to rejoin the lives we had BEFORE the USA forgot they could think for themselves and care about other humans!
110
I’ve lived with severe chronic pain since my 3rd back surgery in 1999. Several more back surgeries after that one too. I was on a higher dosage in the beginning but after a gastric bypass, I asked for a dosage reduction. Ive been a model patient for 20yrs. No abuse, etc. ive been taking the least amount needed per day for years. Every day can be different if I have to measure my pain but I had the medication on hand. Wasn’t unusual to miss a dose based on timing. You just can’t double dose this type of medication. What’s happening now with the reductions forced on me are borderline malpractice. After this month, I’ll get another forced reduction. To prepare me for this, I was prescribe 2 of my extended release morphine 30mg and 1 15mg immediate release. I fell this week. The allowed meds didn’t touch the extra pain . I was told that I’m of a target group being under 65, disabled and on Medicare. I went with my Dr when he moved to a different office because he is the only one that knows all my injuries and diagnosis so well. I’m barely able to walk now after a fall in 2015. The pain never goes away but there are occasional rare days that the pain feels more under control but that’s definitely past tense with all the reductions I’ve had. My Drs PA told me the law dictated the reduction and now need narcan on hand. I’m single and no children. My meds stay in a safe place. What a crock! Yes... i’m Angry! I will never be without pain and it’s going to get worse. What then?
21
I ran into the same problem when I tore my rotator cuff so badly in a fall it had to be sewn on surgically. Before the surgery, which is extremely painful for weeks after, my specialist said she would absolutely NOT prescibe ANY opioids for my pain. And if I wanted any opioids prior to surgery for the excruciating pain, I would have to pee in a cup and sign a contract, according to NJ law. I'm a senior without any past addiction problems. I spent days crying and not being able to sleep. Made me distrust my primary care physician to for treating me so cruelly.
36
@Suzanne—What your physician’s did was malpractice.
I had to have three of the four tendons that make up the rotator cuff re-attached in October of 2016. My orthopedic surgeon gave me an Rx to fill in advance for 60 x 5 mg oxycodone to cover for two weeks. And yes there was a lot of pain: I had the ice water pad, and told to take 600 ibuprofen plus 500 Tylenol three times a day and use the oxycodone as needed. I don’t like narcotics and stopped after five days. At the two week check, I was offered a refill but told them I had 36 left. The PA said he has some patients like me and others who will burn through the first 60 and then another, but he can’t tell before hand.
At a street value of $5@, I could have made some extra cash. That is part of the problem the the CDC is trying to address at the expense of your pain.
6
@Profbam
Regardless of street value there will be opiates out there with needles. If everything was legalized and the amount of what the addicts were able to be quantified there would be less deaths from Fentanyl, coinciding and the end of violent drug cartels. There would be less suicide and less overdoses. Yet here we are playing the war on drugs by telling people in pain tough stuff.
6
It's deja vu all over again Ms. Szalavitz at the great Yogi Berra use to say.
Whenever you have a perversion like our de facto criminal health care system pushing dangerous legal drugs to people you get the opposite response, don't let anybody use it, including the people that really need it.
The solution, don't create the perversion in the first place.
5
THANK YOU!
5
I have a chronic gyn pelvic pain problem that does not respond to opioids. I take a combination of meds; one would think I'd be safe re treating my chronic pain.
Unfortunately, two medications are controlled substances. My doctors have become uneasy about prescribing them. I have excruciating flares but cannot increase dosages; there is a limit on these meds. My insurance won't pay for the truly harmless diazepam vaginal suppository. Research articles show it isn't absorbed in the bloodstream. I pay one hundred dollars a month for them. I get another drug free from the manufacturer. Insurance will only cover it for cancer patients.
I get twenty Botox injections every three months in my vagina. I'm terrified that these will stop working.
I've also done p.t. but a p.t. specialists in pelvic pain problems are now getting two hundred dollars an hour in private practice.
My doctors are caring but tell me they are frightened now re any controlled substances. This has to end; everyone in my chronic pain support group admits they have thought of suicide if their meds stop.
24
There are non-addictive medicines to cure addiction, which have a reported 50 percent success rate over 12 months. Check out this recent VOA radio story about Iboga, for example. https://soundcloud.com/audiobyadam/iboga-africas-anti-addiction
@Adam Phillips
Addiction is not what this is about. It is controlling our pain which for some is not happening. This is very sad.
10
People who misuse opioids grind it up and snort it.
If that's their choice, then that's their choice.
But don't limit me because of their choices. They are the ones misusing the medicine, and they should pay the consequences--not me.
Pain is awful.
22
First I would like to say that state's should not be able to make law's about what our doctors can prescribe for us. If they are being responsible. And Congress and politics have no place in our medical lives. My meds were only cut by 40mgs a day. But has made a huge difference. Everday I am so sad that I woke up again. Everyday I pray to die and end this pain. Pain clinics closing and doctors not prescribing and running for the hills is just inhumane. I always say they shoot horse's don't they?
19
Complex Regional Pain Syndrome. Never heard of it? You sign off on it in the fine print every time you have surgery these days. Also known as the "Suicide Disease". CRPS for short. Rated on the McGill Pain Chart as more painful than natural childbirth. It never stops once it starts. It builds and builds and builds and it's 24/7. Your pain site is on fight. Your body breaks out into bleeding sores. It spreads from the original site, usually from nerve damage from an injury with casting (fully documented during the Civil War) into your organs. And now we CRPS sufferers cannot get opioid relief thanks to the shortsightedness of the new pain control laws because of others' failures. "The Suicide Disease" is a truism. Thanks, doc.
21
Most excellent column. This oldster, having been initiated into the mysteries of possibly chronic, relentless pain last year, ( both events resolved, for now), contemplated all manner of coping, exit strategies. We are finally beginning to accept the reality of death with dignity. Allow us, pain with dignity.
18
Throwing the opiods out with the "bath water of abuse" fails to help those who need monitored pain relief.
Too many all or none solutions today. Focus on finding solutions. There are some....
11
Why does our society have such difficulty with nuance? As described here, the current hysteria over opiods for severe chronic pain is causing cruel, totally avoidable suffering as doctors are coerced into abandoning their patients. This is a meat cleaver applied to a problem requiring a scalpel. How many doctors are unaware of the opioid epidemic and still handing out Oxycontin or Vicodin like candy to anyone who wanders in? The fashionable claim that opioids do not treat chronic pain is nonsense to the millions of patients who have used them for years at minimum doses without becoming addicted, and for whom life is unbearable without them.
This childish all or none approach to problems permeates our society today. We watch in wonderment as the Democrats eat their most promising children because they wore a costume 35 years ago, or because Al Franken posed for a silly sight gag on an airplane. We see the federal government gagging its own scientists on climate change because Republicans cannot accept even minimal constraints on greed for the good of life on earth. We see the Dems forever committing political suicide by railing against gun owners in rural America because a handful of big city dope gangsters can't help shooting each other, and calling citizens racists if they question the wisdom of unlimited immigration.
We are too simple to deal with detail, nuance, or subtlety. Small wonder that Europeans are forever dismayed by the childishness of Americans.
22
I have been a physician for about 45 years, I will tell you that pain relief is important, but opioids are a bad solution. If you keep up with the scandal that is Perdue Pharmaceuticals you may have learned that they developed oral opioids and pushed them beyond their non addictive state. Opioids in the long run develop resistance, that means that you need more over time to get the same effect. This is across the whole spectrum. So Oxycontin, morphine, Fentanyl, codeine, all share that characteristic. What that means is that if you take the medication over time it stops working at the same dose. Additionally, Perdue pushed the notion that if you had significant pain you would not get addicted, and that is false. People get addicted and we are seeing overdose deaths in epidemic proportions, from prescription drugs, not Heroin.
I always felt that treating chronic pain from things like arthritis, fibromyalgia, or intestinal or bladder, with opioids is not a good idea, easy, it works but a bad idea. If other measures don't work, this is likely to cause more problems for chronic pain. A pain specialist may have other options available. Don't fall into Purdue's trap of misinformation, as we have learned, opioids are highly addictive and do kill.
4
@William Trainor As we age, humans become increasingly vulnerable to the terrible damage time and fate can do to our bodies.
Here's hoping the good doctor never has to experience the level of chronic pain that is not only crippling millions of Americans but driving thousands to suicide.
We are not addicted -- we are drug DEPENDENT, the same way diabetics depend on insulin to keep them alive. We know opioids DO work to control pain and allow us to function, because we have found it physically impossible to keep going without them.
Dr. Trainor, you are very fortunate that you've had a life free of crippling daily agony. May you never learn how awful your own words will taste if you have to eat them.
15
@William Trainor
As a former RN, I appreciate your remarks but I also beg to differ.
I was a good patient and went to the doctor when I began having ankle pain. He was a good doc and referred me to ortho. Ortho snapped an x-ray and pronounced my ankle “fine.” But it wasn’t fine so I went back again and again, popping ibuprofen like tic-tacs per his recommendation.
After a year of limping my way through 12 hr shifts, my opposing hip began to ache. Back to Ortho. Snap goes the x-ray and I’m again told I am “fine.” But I’m not fine. PT follows. KT tape. I am desperate. Back to Ortho I go.
What does he do? Refers me out-of-practice to another ORTHO! The FIRST question from the new ortho? “Where is your MRI?” Good f’ing question.
Turns out, 16 months after I first saw Ortho 1, that there is a lesion in my ankle. Surgery follows and the ankle heals, but not the hip.
FF SEVEN YEARS: I can no longer work. I’ve had a pain management specialist for over 6 years. He performs RFA (Radio Frequency Ablation) on my SI Joints every 6-12mos. It dampens the pain enough that I can function (cook, do laundry, light housekeeping) with a low dose opioid.
But remember the ibuprofen? I do—it was my favorite med. My kidneys are toast. And now you want to take the opioid too?
It’s too late to sue Ortho #1. Insurance is beyond my budget. I am a cash-pay pt. What treatment plan do you recommend? Oh wait!
14
@William Trainor, I don't agree that the overdose deaths of epidemic proportions are from prescriptions drugs. Once doctors started cutting back prescriptions, people went to the streets for relief, where the drugs aren't regulated and are tainted with fentanyl. Illegal drugs are causing the most overdose deaths, not prescription.
9
How about hospitals checking out opioids like candy?
Years ago I needed a hip replacement due to a decades ago ski accident.
After the surgery I was on a PCA (patient controlled analgesia) intravenous opioid for over 24 hours, one that I could control when the post operative pain became too strong.
I was in the hospital for three days. After receiving my bill which seemed way to high, I had the hospital print out all the details of my bill in exchange for $40.
But surprise, surprise, while still on the PCA, nurses had already checked out 4 strong opioids from the hospital pharmacy which I never received.
The first night around midnight a male nurse woke me up to ask if I had breakthrough pain - me having no clue what it meant. I said no.
Yet on my bill it showed that I had been giving two high dose Vicodin.
Every single day thereafter, when only needing one 24 hour lasting opioid, they had checked out 2 addition opioids for me ever 4 hours.
I left the on the third day at 11am. Yet my bill showed that i had receive two opioid pill at 12pm and 4pm.
During my three nights in the hospital the nurses were having a jolly good time at their station, so loud that patients could not sleep. They must have been high and happy to make some extra money with the pills they didn't use themselves.
8
@Sarah
I hope you reported this, it certainly sounds like drug diversion.
3
It immediately occurs to me that if I were in horrible pain and unable to get a prescription, I would find out where to get drugs from the street. This situation seems a bit similar to prohibition--people are going to get what they have to have, illegally, if necessary.
I do agree that doctors should be careful--but they should not feel threatened if they have to prescribe large amounts to certain patients. How to prevent that fear? Prosecute only doctors who prescribe large amounts to many people. Illegal prescribing will leave its footprint at the pharmacies.
14
@Ro Mason Sadly, many medical practices send all their chronic pain patients to the one physician in the group who specializes in treating their suffering with opioids. The patients are frequently older, permanently disabled, and arrive with canes, in wheelchairs or on gurneys. There are no cures or solutions for their damaged bodies.
Taking our opioids away and punishing the one doctor willing to treat our pain with the only drugs that control it is beyond cruel. Those of us who don't have many years left find ourselves seriously considering an early exit to be the only relief from the hell we've been forced into, thanks to ignorant politicians and the Drug Enforcement Agency.
Recreational drug users overdose and die because they combine five to seven different illegal narcotics and wash them down with several shots of alcohol, or inject heroin containing a "fentanyl surprise" into their veins.
How will denying prescription relief to pain patients protect addicts who can obtain all the injectable narcotics they want on the street?
9
Maia Szalavits is another in another long line of apologists for the pharmaceutical industry. Arguing that some people need pain medications as a reason to tread lightly. Given that 10’s of thousands of people die annually from opioid overdoses and the industry has been shown to fuel this addiction crisis seems a bit disingenuous. So we can’t craft practices and protocols that better target true sufferers? How about just not paying physicians for prescribing? It is hard to imagine this person calling themselves an analyst which such poor reasoning skills. The NYT should focus on analysts who truly have some ideas of how to address this most pressing problem. Not those who bring up simple observations that don’t bring the discussion any closer to dealing with the thousands of deaths.
3
Thank you for pointing out that opioid pain relief is a necessity for many. I have reactions to multiple pain relievers and cannot take them. When my knee pain got to the point that I was passing out (literally) from the pain, opioids were the only medicine that worked. When the knee swelled three times in two months, I ran out of my initial prescribed dose, and the doctor fought against refilling it, even though I had only taken 15 pills in that time. Opioids do not make me high, they just allow me to function. After much argument, he finally did, but if I was not able to solve my issue with a knee replacement, I'm sure this would be an ongoing battle. The pain is indescribable. No one should have to live with it. I know addicts and know this is a problem, but feel this is a case of throwing the baby out with the bath water. As in all things, we need a balanced approach, not one size fits all.
27
And while people in pain are not allowed to get pain medication, those addicted to drugs are supplied with a different kind of narcotic, so they are still addicted to drugs (often at tax payer expense and often for the rest of their lives) while normal people in pain cannot get them.
Interesting.
10
The important piece of information is that "less than 8 % of chronic pain patients become addicted". So there really is no justification for the CDC and drug enforcement to torture and murder (by suicide) pain patients.
27
One thing is for certain - we need more R&D into the pathology of pain and alternate pain killers. It is unacceptable to have an overdose rate that is higher auto accidents and gun deaths combined.
It is equally unacceptable to have people who are sentenced to live in constant pain to protect them from living in addiction.
We have the research facilities; we have the talent; and we have a government that should be able to fund NIH grants. Do we have the political will?
27
@Cathy, studies show that prescribing opioids to chronic pain patients is ineffective in reducing their pain. prescribing opioids sentences them to pain, plus the problems of the opioids.
we do need better treatments, for sure
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4292950/
4
@Cathy
I agree. As a pt with a pain management specialist, I am constantly quizzing him about alternate treatments. One of the most promising is LDN (Low Dose Naltrexone). He refuses to prescribe it or it’s cousin, ULDN (Ultra Low Dose Naltrexone) b/c to do so would be “off-label,” and he is concerned about the limited availability of studies.
As a former RN, I get it, but naltrexone has been around for decades, has an excellent track record, and, in this instance, would be prescribed in minute to small dosages—well under the normal dosage. No drug company can make money off of this now-generic drug, and studies are expensive and arduous. So patients like me have to search for the rare brave soul willing to go down the rabbit hole with us (as in, prescribe off-label). That too is expensive—esp when there is no guarantee of success in treatment.
As will be any new med to come out of R&D.
For cash pay patients like myself, any new med is out of reach.
I’ve made lifestyle changes, but there is a limit to how much you can change and still have a life worth living.
4
@bill zorn
One size doesn’t fit all pain.
4
Does this not have so much to do with patients not having a relationship with a good primary care physician who they know and who knows them? Someone who knows if the individual is a 'drug seeker'? Someone who knows whether the patient is a person who suffers silently or exaggerates pain? Knowing when the pain is likely to be from an obvious source or whether it indicates further investigation is indicated? We need better relationships with our providers and they need to know us as individuals and know us over time.
7
@peter Many primary care physicians work for corporations that require them to see a specified number of patients per day and spend no more than a few minutes with each case. Those who take more than the allotted time with suffering patients are penalized.
Our doctors would prefer to give us better care, but the accounts and business managers in charge of their time won't permit it.
Gotta love America's for-profit medical industry.
5
Due to a lower-back surgery that didn't go well, I was heavily dependent on a certain opioid to function. When I started craving more than my prescription allowed per day, I knew there was a problem.
I enrolled in my state's medical cannabis oil program and began using a CBD:THC mixed tincture dose alongside each dose of the opioid. Slowly, I reduced the dose of the opioid. I took it very slowly. Going off a drug like that isn't easy. But I persisted. Finally, in the end, all I needed was the dose of the tincture instead of any of the opioid.
And now, I only take the oil as needed.
I offer my story as an illustration of how alternatives are out there and can work if only bureaucracy and needless archaic legislation didn't stand in the way.
22
Maia, I live in 24/7 Chronic pain & I just wanted to say thank you for writing this. It’s definitely a start in a good direction for the media. I don’t know if things will get better for us but with articles like this, I’m hoping it does. Hopefully other major papers/news do the same.
29
years ago my wife was slowly dying from cancer.
she was prescribed an opiate..her mother questioned the good doctor about potential addiction. The doctor replied addiction would not be her biggest problem. Clearly opiates have a time and place, and as to people having left over pills...I think a few too many is better than way too few.
53
@tom and clearly 2/3 of the patients are not addicts or in chronic pain situations ..if anything they are in short term pain from injury or surgery and i agree its better to have a few extra
7
once again,the American journalistic
establishment and the hair-on-fire
political class have joined together
to cause misery to innocent citizens.
first of all,the vast majority of people
who take opioids do it safely as I myself
sometimes do. second of all, opioid
addiction is not a disease in the same
sense that cancer or leukemia or Crones
is a disease. it is ,at least at first, a choice.
whenever an issue arises which can
garner a rating or a political percentage
point,journalists and politicians fall over
each other to exaggerate the dangers
to the general public. yes,we must deal
with the drug epidemic in America, but
without driving ourselves into a frenzy.
23
@Frank I believe you should educate yourself concerning addiction. Addicts are born that way. The gene they inherited isn't their fault anymore than the color of their eyes. That gene doesnt turn off their craving for drugs. Normal people have an ability to stop, addicts do not. Not all addicts started by choice. Generalizing about that choice is just like saying all pain medicine user's are addicts. Many addicts have underlying mental health issues that have never been addressed. I educated myself after my son became an addict. I thought it was a choice too, until I did a great deal of research and found the real truth. Lastly, addiction tend to run in families which further backs up the bad gene theory. I know for my son this was true. Addiction was in my husband's family 5 generations deep. Hopefully, with more research in the very near future, we will be able to help turn off the bad gene and finally have a cure for addiction.
16
@GrannyJayne
Addiction is complex. The theory that addicts are destined by their genes and their brains are broken is not supported by science. That black and white belief system is promoted by AA as the only way to understand and treat addiction, but it is not. It isn’t even very effective.
Please continue to educate yourself by looking at other models: cognitive behavioral therapy, CRAFT, etc. that recognize the power of individuals to change.
BTW. My son is a recovering addict,too.
5
Where is it written that being addicted to opioid pain medication is worse than being in chronic intense pain?
183
@SqueakyRat
I'll tell you "where it is written." Search for OIH
- opioid induced hyperalgesia.
And no. Hyper Algesia is not a new ethnic enclave in the Balkans. Although the world disruption may be as profound as that attributed Gavrilo Princip.
4
Common sense says a good Dr knows where to draw the line, The comparison between those suffering addiction vs those under prescribed has to be gigantic at this point.
11
@BM
A good doctor - who has been trained in addiction and pain medication - does know "where to draw the line." But medical schools do not teach general physicians about addiction. Pain specialists are much less likely to prescribe opioids - because they have received necessary training.
2
@dr brian reid Dr. It would seem obvious even to me if one were to be begging for another prescription after a reasonable time to heal. Dr's are supposed to be our best and brightest and I will not accept that they, through all the training, could not on their own figure this out. That's just not an excuse. Maybe if they weren't going to Monte Carlo on Perdues dime to give a speech on toe nail fungus they would be more lets say "common sensible" in the way they prescribe.
4
Thank you so much for addressing this very real and pervasive problem.
There are lists currently being made of CPP (Chronic Pain Patients) who have left evidence behind as to why they chose to end their lives early, directly related to force tapering or doctor abandonment.
We are literally fighting for our lives.
I myself have had 14 failed surgeries and I invite anyone to look at my FB profile and check out my xray.
I have been forced tapered dramatically and can no longer carry out basic self care functions, such as showering, doing laundry or leaving my house for much more than one or two physician appts a month.
I'm very much in favor of the Right to Die laws, only wishing we could amend them to include patients with non-terminal diagnosis, like Switzerland or Belgium.
If the govt feels it's allowable to take my quality of life away and condemn me to living in severe pain, which can only be described as torture, then I should be allowed the same compassion shown to beloved pets who are euthanized to stop their suffering.
I'd also like to point out that living in this kind of pain doesn't only effect the patient, but their families as well.
Anyone whose had to watch a loved one suffer through cancer can surely empathize. Except for CPP there is no getting better and death must be chosen.
Alternative treatments are expensive, rarely covered by ins, take much time away from work and don't work on their own.
A multi-modality approach is best, including pain meds.
91
As someone who had chronic pain for three years starting in 2003 from a neuropathic injury caused by surgery, I can say that firstly I was able to keep my job (and thus my health insurance-as someone who worked at a small business I would not have been eligible for COBRA if laid off) because my pain was managed with opiates allowing me to go to work and function; secondly, the opiates did not lead to lead to my life spiraling out of control nor did I feel the need to take more and more; thirdly, when my underlying medical condition that led to the surgery was cured, I was lucky enough to have access to a pain specialist and the insurance support to be able to try many therapeutic approaches to address my chronic neuropathic pain, and extremely fortunate that a combination of a TENS device and long term physical therapy ultimately worked. But I know I was lucky, many people have chronic pain that will never stop, and to live their lives they need pain killers, which includes opiates.
I will add that over the years I have occasionally been prescribed opiate painkillers short term and never had any problem stopping.
It seems to me that an interesting avenue of research would be what are the underlying factors that lead some people to escalating use and eventual overdose while others have no problem. But until we understand that better, it is important to remember, as this article points out, that the lack of painkillers can lead to ruined lives and premature death too.
90
@Michael Perot We already know why some people are addicts while others are not. Addicts are born that way with a defective gene that won't turn off. That is why they say addiction is a disease. We are currently researching a way to turn that gene off. Lastly, perhaps then all drug addiction will be cured instead of managed. The reason rehab doesn't work always is because the addict has to want to make behavior changes and work the program. We need a cure to save lives.
2
@Michael Perot
So Michael for the future if your company has an insurance plan from an insurance company [ not self insured] then you are eligible for COBRA. COBRA is mandated by the U.S. you are eligible for up to six months and under certain circumstances eighteen months.
4
@oscar jr
I use a Tens device. Medicare will not pay for it or the electrodes and lead wires. Doctors don't prescribe it because it's time confusing and takes a lot of patient experimentation.
When Medicare stopped covering it people with lower back problems who had no place to go did themselves in.
4
I feel so badly for people with chronic pain right now. This opioid thing is a huge overreaction. I broke my shoulder and let me tell you, it hurts really badly. I cannot sleep. I was cut off of pain meds way too early, but I can take it because there is going to be an end to it. I do not have chronic pain. This is so wrong what is happening to these people, and it could be any one of us someday. Not everyone gets addicted, and in fact, most of us do not. But we all have to suffer because of the addicts. I am all for giving them free access to Methadone programs. I want them to be helped too. But lets stop making everyone suffer because of that minority of people. It's cruel
139
I consider myself a tough person, I had my child without pain relief, I also had a herniated disc in my back that took literally months to go away, the pain was unbearable. I took Tylenol and Advil (it didn't help...). I couldn't even drive the car, and in that time I didn't know if it would ever get better, it was a horrible, terrible state of mind. I am not going to judge anyone for doing what they need to do to ease the pain of terrible chronic conditions. The poor woman in this article with the bladder disease, people with cancer, etc, it is a crime to leave them without help even if it means addiction. We need to weed out those who truly need helpand those abusing the system.
74
So I'm disabled and take a low dose opioid medicine. What I've found is when you use these medicines folks look at you with suspicion or you get a little lecture on the dangers of these medicines. I think at times we are working for the abusers with the hoops that we need to jump through. Side note, My wife likes sudafed for her seasonal allergy problem. You need to show your drivers license and are limited to a certain amount per month. I joke with the cashier that in some states you could walk into many stores and show a license and walk out with a AR-15 and come back in a week or so and pick up a Glock pistol with 9 or 19 ? shots,and week later, you get it.
43
@FJS love your comment. Laughed sadly. Then thought - who are you kidding? Wait a week? They can get another one the next day!
14
Having been previously married to a chronic pain patient managed on high doses of legally prescribed oxycontin I've been watching the war against opioid use very closely. It's patently obvious to me that chronic pain patients are suffering and are going to continue to suffer greatly in this debate over the crisis.
My marriage was lost largely due to poor pain management and had I found a better pain specialist earlier I think things might have happened differently. Like so many issues in our society I see very little hope because the current approach to the problem is simply not accommodating those who truly need careful and compassionate pain management. They are basically being treated as expendable by the families of those lost who only want the supply curtailed. Suicide as a response comes as no surprise, it should be tracked and expected.
39
It’s an unfortunate fact that physicians started the opioid addiction crisis by failing to address the risks of addiction rationally. To a large extent it was due to pharmaceutical businesses misinforming them and part of the problem is that physicians cannot know medicines and epidemiology as well as pharmacists and agencies like the CDC. Patients needed pain relief and that was the priority.
8
@Casual Observer Your point is unclear to me. Is there an argument here?
2
@Casual Observer The CDC developed its restrictive opioid prescribing "recommendations" after consulting with Andrew Kolodny, an addiction specialist who owned a major share of Rainbow House, a profitable chain of drug rehabilitation centers. Kolodny is also a founder of Physicians for Responsible Opioid Prescribing, which is adamantly opposed to opioids for any reason other than end-stage cancer.
The CDC never bothered to consult with pain specialists or ask a single chronic pain patient for input. They also kept the names of committee members secret to avoid criticism.
The agency later issued a partial retraction for their flawed methodology.
11
Until we make mental health and pain management more lucrative than being a cardiologist or a gastroenterologist, nothing will change.
16
I practiced medicine years ago when a wave patients with chronic pain sued Doctors for undertreating their pain. It's happening again!
The pendulum has swung again with primarily young Doctors once again undertreating pain. Yes there is some excessive prescribing but the vast majority of deaths are from illegal drugs. Patients need to be evaluated properly and treated. Pain is inherently subjective and the most important support a patient needs is an accessible caring Doctor PA or NP.
I strongly believe that most chronic pain patients Should Not be on Chronic opiods BUT they NEED opiods at home when necessary for a good night's sleep or just to spend an evening with family and friends or to stop a cycle of breakthrough pain. When you read about opiods use it always sounds like all of nothing.
I think the women who closed her quilt store should sue her Doctor.
Having some pain medicine around gives piece of mind and creates anxiety when it's not.
We need some sanity in these edicts and regulations surrounding the use and prescribing of opiods.
47
@jm I just took my prescribed muscle relaxant and opioid I am waiting for them to kick in. Currently I’ve had four hours of sleep. I am hoping to get four more. I am reading all the literature on new treatments in the works for chronic pain management. If/when they improve, I’ll happily give up my opiods. In the meantime, I live in fear of not being able to get them.
28
@Karen
Are you reading the literature on Cognitive Behavior Therapy for chronic pain?
1
This is an all too typical case of what happens when the individual case variations found in medicine collide with the rigid dictates of law, especially when legal pressure is influenced by political considerations.
The country is currently in the midst of an epidemic of opioid use that's largely the result of neglect: despite the existence of DEA Schedule 2, a Federal regulatory regime designed to make these substances available by prescription, but with fairly stringent controls on amounts and refills, for decades after the scheduling was drawn up, enforcement mechanisms were left almost entirely to the states! There was no means of coordination or comparison in tracking prescriptions across state lines- something that could have been implemented long ago, especially by the late 1990s, using the capabilities of the Internet. Instead, what resulted was a mind-boggling lack of accountability in some states that easily allowed diversions of mass quantities. At the same time, physicians were given misleading information on opioids by profit-seeking commission salespeople, and opioids began being prescribed in large quantities for acute pain problems that were neither intractable or particularly severe.
Now that enormous damage has been done, the institutions who fell down on the job of oversight to prevent the problem are overcompensating by restricting prescriptions to patients with chronic and intractable pain- the folks with the most justifiable reason to use opioids.
38
I came into this debate as a new RN circa 1990. Post surgical cases were prescribed Tylenol. People were suffering greatly. Nobody with more than a two month prognosis received opioids, and that was the end of the story. It was embarrassing, and distressing. I left hospital nursing, as I could not cope with the non-treatment of pain.
A short 10 years later, I found people with chronic nonspecific back pain were prescribed large doses of opiates. We know what the end result of that has been.
7
Thank you Ms. Szalavitz for a much-needed article. I am a health practitioner who sees many patients with chronic pain, some of them maintained on opiates, including buprenorphine. All of those I've seen are serious people who have made contributions to society, and many continue to do so, including some who have resorted to illegal sources when their prescription was refused or reduced. One of my patients described a difference observed in nursing home residents in the U.S. and Canada, where many here are in misery and inactivity because of inadequate pain medication compared to our northern neighbors. An additional area of controversy is where people may want to try medicinal cannabis to reduce their use of opioids but can't do so for fear of losing their primary pain prescription. People who suffer from chronic pain need our compassion and are not to be feared or treated as drug addicts. Their views should be given prominence when planning public policy and compassionate treatment. Still find it hard to empathize with these folks? Imagine suffering the kind of pain 24 by 7 by the woman in the article with incurable bladder disease. Any of us can suddenly find ourselves in that predicament. All it takes is a serious accident or illness.
57
@Knowledge Is Power
Thank you!
8
While I acknowledge that there is certainly a problem with opioid addiction in America, I’ve witnessed a tendency for doctors to prescribe fewer narcotics and weaker narcotics even for post surgery pain (myself included).
Our everlasting Puritanical roots would have us do away with all pain relief. No matter what. In too many circles, suffering pain is considered ennobling, and honorable. Relieving pain is weak, passive, effeminate.
And finally, rarely if ever does one see any serious discussion of why so many seek escape and relief with drugs legal or illegal, in the first place. Ever notice where the opioid crisis is worst? Upper east side of Manhattan? Nope. Greenwich, Connecticut? Nope. Wheeling, West Virginia? Mmmm. Rural Ohio? Mmm. Wake up you armchair critics of drug misuse!
67
@Freestyler
Excellent point. Woody Allan taught us that Park Avenue pscyhoanalysts are available to the wealthy. Mental health care - or any health care - is widely unavailable to poverty stricken counties. No medical doctor? No psychologist? Medicating oneself appears rational in the absence of science based treatment.
15
I can’t help but wonder where all of the sanctimony regarding opioid abuse was when Duragesic patches were still being prescribed. To say nothing of the fact that there are actually fentanyl lollipops.
Painkillers are a necessary aspect of healthcare, whether we like it or not. Physicians are bound by an oath that requires opioids, until and unless a practical substitute for them is discovered.
20
Thank you so much for writing this. Chronic pain patients so often are the voiceless in this debate. People assume we're just addicts, faking it for pills, the pain can't be that bad, surely there's other treatments, and so on. We've reached a point now where it seems, even with palliative cancer and postsurgical patients being denied opioids, they're not seen as legitimate treatment anymore.
I have damage to my spinal cord in the neck and lumbosacral spinal arthritis. I'm 37 years old. The pain can be excruciating and has also given me central sensitisation syndrome. I'm already on pregabalin, nortriptyline, muscle relaxants, high dose paracetamol. If the 40mg daily oxycodone (which isn't a super high dose) was suddenly taken away, I would consider suicide too. That we're happy to condemn millions to lives of unimaginable suffering in pursuit of pure ideology says it all about where our society is at in the 21st century
65
Thirty percent of the medical opioid production is consumed in the US, for 4.5% of the world population. Clearly they are over prescribed and it’s far from the truth that patients are left suffering now where physicians are more restrictive in prescribing. Most patients tolerate a taper to lower doses with preserved daily level of activity and often a better quality of life. These medications have serious side effects that often outmatch the benefit.
3
@Oliver Herfort And the patients’ views are not important? You decide what they need based on statistical comparisons that say nothing about whether pain is adequately treated elsewhere? We use more prescriptions for a number of conditions than other countries do. Does that mean they are overprescribed as well? With every other medical condition, doctors ask their patients if the treatment seems to be working. With opioids it seems patients will be told, not asked, whether it’s working or not.
51
@Oliver Herfort
If doctors forcefully tapered people too rapidly off antidepressants causing untold misery and multiple suicides from withdrawal symptoms (as they cause physical dependence) there'd be no end of lawsuits. But because it's opioids and people with chronic pain, something many view with deep suspicion, sympathy is in short supply.
43
Opioids are not the answer to chronic pain, anecdotes not withstanding.
Every death through overdose tells you that.
2
@Oliver Herfort It depends on the chronic pain. It depends on the opiod. Burprenorphine is an opiod, and yet it has saved countless lives, and is used to treat chronic pain (in Europe I believe it is approved for it) as well as addiction.
13
@RamS: Buprenorphine is used mostly to combat opioid addiction not to treat pain.
1
@Oliver Herfort One could also say certain drugs used for last-resort treatment-resistant epilepsy are not "the answer," because they can cause dependence and death by overdose. In reality there is no "the answer." There's only a list of therapies to try, with controlled substances at the very end of the list, for use when nothing else makes a difference.
Especially with rare conditions that have not been well-studied (and rare variants of common conditions that fail to respond to standard treatments), anecdotes may occasionally be the best information we have.
25
I am not going to argue in favour of opioids, especially when research has proven that for use in treating chronic pain opioids actually decrease tolerance to chronic pain, not increase it.
However, I am highly suspicious of two things happening here.
First, I'm wondering what supports are being put in place for patients tapering off opioids. Years ago, doctors told their patients to expect tapering to be like "going off your morning cup of coffee". Now we know that tapering too quickly can be fatal. Patients need to be made aware that they will experience substantially increased pain for a short period of time during the initial taper - if they are not, then they may be moved to extremes, believing the increased pain will last forever. (The pain is actually a symptom of opioid withdrawal, and will dissipate in a couple of days) .
Second, I'm wondering what supports are being put in place for patients to manage their pain instead of opioids. Are they just being told that their pain medication is being discontinued and left that way? Or are they given resources to access physiotherapy, massage therapy, CBT, nerve blocks, heat therapy and other complimentary therapies, or other non-opioid medications? What are their options for managing break-through pain, mobility issues, or social issues as they navigate a new way of interacting with the world?
Are patients getting any support to manage their conditions once the opioids are out of the picture or not?
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@C Many patients are on long-term opioids precisely because we have already failed every other alternative, in some cases including multidisciplinary pain rehab programs with all the modalities you describe and many, many more.
For twenty years I have been in pain management for severe refractory IC, the same condition as the patient in the first paragraph. I have been through every treatment and therapy that exists - diet, pouring medication into my own bladder several times a day, neurostimuation, alternative therapies, and even a multi-modal pain rehab program including extensive psychological supports. None of these made the slightest bit of difference in my condition (poorly understood, but likely genetic autoimmune disease).
I have never experienced tolerance; same dose for 20 years. The one exception: I did an ultra-slow taper for pregnancy, and I did not have significant withdrawal symptoms. I did, however, lose the ability to leave my bathroom. At CDC-recommended dosage, I need a toilet approximately every ten minutes. Without any pain medication at all, it's every minute or two.
The experience you describe, where alternative therapies support opioid taper, is certainly an experience that many patients have. There are also many patients for whom opioid therapy is a lifelong disability accommodation, allowing access to normal life for incurable conditions after every alternative has already failed. Palliative care is not just for end of life.
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@C
This is the US. Support for tapering off opioids will be dependent on where you are on the health care hierarchy. Do you have good insurance through your employer? Are you on Medicaid, Medicare? Do you live in an area with plenty of health care professionals? Do you have high deductible insurance or none?
My guess would be that maybe 10% would get the care you ask about.
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@C
"(The pain is actually a symptom of opioid withdrawal, and will dissipate in a couple of days) ."
Where did you get those unsubstantiated ideas?
Given that the opiates were prescribed to treat pain, the
pain can't be a symptom of opioid withdrawal.
Those people who are in severe, intractable pain don't need a "new way of interacting with the world" any more than diabetics "Need a new way of interacting with the world without insulin."
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It is about time someone wrote on this issue. Doctors are either being stampeded or coerced into reducing/not prescribing opioids. The potential impact for individuals with chronic pain -- or short term acute pain -- is very dangerous.
My wife suffers from chronic, at times debilitating, depression. Her psychiatrist prescribed vicodin years ago as he had read research suggesting opioids can help those with depression. It helped. But now, in CT psychiatrists can no longer prescribe vicodin.
A couple of years ago I had a very very very painful acute medical situation. I went to a physician who performed a very painful (local anesthesia doesn't necessarily stop acute pain) procedure which after it was over left me (temporarily) in greater pain than before. No pain pills though and I remained in acute pain for over a day.
I also suffer from chronic pain that will never go away. It's bearable now on most days but the long term prognosis is that it gets worse. My fear is that it will reach a point where the pain is not bearable but I won't be able to find anyone to prescribe opiods.
When someone has chronic pain, particularly in their later years, what is the problem with prescribing opioids? Let's say I reach my 70's and am in constant debilitating pain from my current disorder or something new. Which is better -- addiction or pain? I say addiction. What will you be saving me from by not treating my pain in the best way possible?
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@Ralphie Honest doctors will tell you that the reason there is no objection to opioids for cancer patients is that we expect them to die soon anyway. Apparently the feeling is that if a person has 18 months to live we should make them comfortable, but if they have 18 years to live, they can suffer a little longer.
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@Ralphie Addicts are born that with a disease They are born with a defective gene if you will. That gene doesn't turn off to using narcotics. We are currently researching how to turn the bad gene off to cure addiction. The reason rehab fails is because the addict doesn't want to use the tools they are taught to manage their behavior. Lastly, I am actually shocked at how many people actually misunderstand addiction. It is then no wonder that our medical doctor's would be equally uneducated about why people become addicts.
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@Bob
Sadly, now even cancer and hospice patients are being effected by these draconian protocols.
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There is no question that the overuse of narcotics (#90 Vicodin, Refills x3 for a wisdom tooth extraction) have been done. It is far easier to write for refills than to take a call from a pesky patient wanting ten more tablets to allow sleep at night, so write for many, write for refills.
That aside, it is also a very heavy boot of the state and federal authorities to make caring but cautious practitioners worry that they will be investigated, or have automatic programs that are now part of most physicians' practice, monitor for exceeding some arbitrary guideline. It is very expensive and intimidating to defend against some of these things, and the safest route is to back down to giving fewer tablets and never any refills, or have laws require yet another office visit to 'reassess' a static condition. The cost and time and for some people lack of transportation for such visits is a waste.
I don't know how to balance, but there is the real mistreatment and infliction of pain on those who previously were not impaired nor suffering brought on by the pendulum swinging too far. Yes, there were abuses. But most of these can be seen, and a little more education and continued medical education once again allow those with otherwise unmanageable, incurable situations to be helped.
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@reid
When was the last time scripts were written, Vicodin #90 refill x 3? No refills on controlled meds.
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Maia - thank you for your rational understanding of chronic pain. I have been taking opioids for over five years, after taking high dose NSAIDS for over 30 years. My kidneys can’t take it anymore, I’m anemic and I have poor clotting despite not taking NSAIDS recently. I have hip dysplasia and at 53 I’ve had one hip replaced twice and the other once. Add to that the car accident 27 years ago that destroyed my neck, with cervical disk replacement surgery last year, an I have a lot of pain every day. I take hydrocodone. I have been forced to take less and less by these guidelines that were never supposed to apply to me. I’ve never failed the mandatory drug tests. I’ve tried medical marijuana- it doesn’t work for me. I’m not looking to be pain free, just capable of working and supporting myself. I don’t get “high”. If I’m lucky, I sleep better because I’m not in so much pain. I understand that my doctor is under immense pressure to “get me off opiates”, but I’m jumping through all the hoops and the levels seem arbitrary. I suppose that I could go on disability and just sit at home in misery, but that is a sure way to a rapid death. I’m not suicidal, but if you take away everything that I value - my job, my self worth and my ability to take care of myself, then I don’t have any reason to live. At the very least, I should have the right to be seen as an individual, with individual needs as far as pain control.
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@M It seems that "medical marijuana" for chronic pain is a cruel myth, perpetuated as propaganda to increase the legal access to marijuana so that it will be available for recreational use. It is not usually effective in the treatment of pain.
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Bravo Maia, wonderful job, as always!
I’m a chronic pain patient. I’ve been on opioids for 19 years and they help me tremendously. Sadly I’m like many patients who feel their future’s have become uncertain, at the very best. This isn’t a result of our underlying disease or disability. It’s because it’s become increasingly difficult, if not impossible to get the medications that allow us to have a decent quality of life.
Many have committed suicide. I’ve maintained a registry of pain patients who committed suicide for about 5 years now. I’ve lost close friends and acquaintances. Some days I’m afraid to even check my email, not wanting to find out about yet another death brought on by unnecessary suffering. At present, the count of lives lost is in the mid 200’s and climbing at what seems like an ever-increasing pace.
Chronic pain is difficult to treat and patients and their prescribers should have access to all the weapons modern medicine possesses. This doesn’t mean every patient, or even most patients need opioids, but they shouldn’t be withheld when truly necessary either. Each day I pray our country will come to its senses and realize the harm that’s being imparted on patients with pain.
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@Anne Fuqua
The New York Times has suggested that American physicians look to Canada for guidance. But particularly, they mean look to Vancouver where the British Columbia Centre on Substance Use is codifying world-class standards for pain relief and for addiction treatment. Those guidelines do not call for sudden opioid or benzodiazepine discontinuation. Physicians are guided that "pain should be treated." Specific guidelines refer to the WHO "pain ladder." CDC guidelines focused on STARTING opioids. Once patients are dependent (8% of 18 million amounts to nearly 2 million who need addiction treatment), then physicians are faced with a different illness. "Rehabs" are not hospitals, so folks who recognize their addiction have little opportunity to access science based medical treatment for addiction.
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@dr brian reid
I understand what you're saying. You’re right, the CDC Guidelines weren't meant to address the needs of current patients. When addiction exists, patients deserve real treatment, not a few months by the ocean singing ""Kum By Yah." I’m not knocking 12 Step Programs as a supportive measure, but they aren’t treatment.
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@Anne Fuqua
Yes physicians should have every treatment available to them. Unfortunately many physicians and even more lay people believe that opioids are always the most efficacious treatment of all forms of pain. This is complete myth and I don't think anyone should be treated based on myths.
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