Iwas with my pain doctor for 20 years at the same clinic and on the same dosage when on 4-23-16 the medication that controlled my pain was stopped. I arrived for routine follow-up when a new doctor I had never seen walked in to tell me he is stopping all pain medication for each person within one month. They released me as a patient.
I have Spinal Bifida, Scoliosis, Fibromyalgia, chronic kidney stones and more. My worst pain is from migraines, including chronic cluster migraines, several ruptured disks from a back injury and severe disk degeneration and chronic kidney stones.
After my the clinic It took me six months to find a clinic to accept me as a patient and I was treated as a new patient.
On 8-23-2018 I was having one of the worst cluster migraines On it’s 5th day, I had a flare up from my disk rupture, and my chronic kidney stones started dropping. This was my 4th kidney stone episode this year. I was in horrific pain.
I have a pain contract so my son called the clinic to let them know he was taking me to the ER. He was told he could take me but under no circumstances could they give me any pain medication. My son called 3 more times; on the 3rd call was told we needed permission from the doctor, and he had already left for the day. The next day my son was told the same and the next appointment we were told the same. The ER could not treat mine.
This doctor was fired for what he did to me and the doctor who took over started to give me my pain medication back
This hysteria did not come around by accident. It was born of the press campaign that accompanied the CDC's launch of its "Guidelines for Prescribing Opioids in Primary Care." That was issued in March, 2016.
It was designed to attract attention for CDC Director Tom Frieden's job hunt, as President Obama's term would soon be over and he would need a job. It worked. It got him backing of the .01% for an institute of his very own, but at the cost of leaving patients condemned to agony.
Of course blame is also due to the eager state legislators who jumped on the bandwagon to destroy the lives of constituents doomed to experience severe chronic pain.
Read the "Guidelines." It's truly third rate, telling doctors that before prescribing an opioid they have to first try nearly a dozen therapies, including "alternative" therapies that have failed blinded, objective trials. (If a researcher uses subjective outcomes without objective measures many "woo woo" therapies can be "proved" to conquer physical ailments. Beware.)
When it was launched Frieden and CDC put all the blame on doctors and patients. Corporate interests were spared, including drug companies and some very negligent distributors. In fact, the names of "experts" who worked on the report have been kept secret -- it is alleged that they include persons with financial interests in "alternative" and other treatments the report endorses.
4
What is wrong with "being addicted" to not being in physical agony--the agony which necessitated the opioid in the first place? People who have never tried to walk a mile in excruciatingly painful shoes (not literally) find it easy to view intolerance to pain as a moral failing and unfairly ennoble stoicism in the face of needless suffering. (This latter mindset is endemic to so many religions--theistic or not. Religion should not be imposed on patients).
3
Sad, but the government and medical society said that pain level was an additional vital sign, then pushed pain relief. Soon there were a small number of patients who do become hooked at first use. Then with the abusers using opioids in abundant and sometimes lethal amounts the same groups have erred in the opposite direction. I’m waiting for one of the experts to have a total knee surgery. I’m not saying that Tylenol doesn’t help, it does, just not enough the first few days. As a surgeon I deployed long acting xylocaine around the incision to decreased he needed narcotic meds so there was fewer bowel and pulmonary problems. Still enough comfort to get people moving decreases blood clots post operation. Opioids are a valuable tool and need judicious use.
5
Opiods have genuine therapeutic uses in the practice of medicine and surgery. As a surgeon, it is up to me to prescribe these pharmaceuticals safely for the effective pain-relief of my patients. Analgesia is complicated and must be tailored to the needs of each patient individually. Opiods are but one tool in effective postoperative relief of pain and relief of chronic pain in those who are recovering/living with pain. I have to give my patients the best care and constantly upgrade my knowledge/training on what is available for safe and effective prescribing. I remember to "First do no harm".
9
Even post op cancer patients have to fight to get any pain relief! I went to a major cancer center but got nothing for the initial biopsy, which involved inserting 6 inch long needles a number of times, into my breast. The procedure was, at least, partially numbed but they refused to give me any pills to take home. Around midnight, the lidocaine suddenly wore off and I began screaming and crying in pain. I have never experienced anything like that, ever. When I discussed further surgery with their doctor, she claimed there is a rule in our state that she could prescribe only 3 days worth of pills. I asked the pharmacist--he never heard of such a rule. She was straight out lying. Needless to say, I chose a different surgeon, but she wanted to only give codeine. I made it clear: no percocets, no surgery! At least she did not make up non-existent laws! Now, I have persistent pain and quite likely may for the rest of my life, due to ongoing treatment. I have no idea where to get any help for pain. When I get too miserable, I resort to alcohol--reduced to the primitive anodyne used before people knew about the blessing of opium. I guess next I'll try biting on a stick, like they do in the Westerns. Thank you War on Drugs!!
18
Imagine if this is how Doctors responded to the public perception of anything else they do.
"Vaccines cause autism"
doctors:
"Pot cures cancer"
doctors:
Amen. My mother had Fibromyalsia and was put on pretty strong painkillers; but without them, she'd be in pain and in bed. It was no way to live -- after years and years, her tolerance did go up, but the Doctors ended up lowering her dose bit by bit, because of pressures of prescribing opiates. The pharmacists looked at her like she was a monster, and some outright refused to fill them. It was awful -- to be treated like a criminal when you're actually in REAL pain and REALLY need relief... now she's watching over me from above, and is no longer in any pain....
11
Thank you for writing about this issue! As a former hospice nurse I saw people all the time in chronic pain and their doctors had prescribed opioid relief but they wouldn't use it....afraid of getting "hooked". It sometimes takes many conversations to get patients to see the benefits of pain relief...it makes a world of difference in their quality of life and the time they have with their loved ones. There IS a place for opioids in medical practice and I'm afraid that message is getting lost in the wake of the non medical opioid crisis.
19
Best man at our wedding became stricken with Bladder cancer and after Chemo got untreatable non stop diarrhea
The only treatment that kept him from 24/7 pooing was codiene for it's constipating qualities ,so at times it is needed and a negative effect of a drug becomes a positive one.
11
Pharmaceutical greed has left those in real pain no options. Thank you greed for helping people remain in pain.
10
Thanks for this illuminating column.
All hail, Cleveland Clinic -- for those who are not familiar with it, take my word for it, this is a fantastic institution.
7
I wonder if they can fix my leg?
NYT and Dr. Sekeres, please do not use the word narcotic when referencing opioids used for medical purposes. 'Narcotic' has illegal or illicit connotations and has been primarily used in law enforcement contexts. That terminology can only make worried patients more anxious.
7
Chronic pain is a killer. The pain itself doesn't kill you, but it makes you WANT to die. Denying opioids or even the weaker opiates, which are no less likely to create dependency (a wholly different animal from addiction)is cruel and inhuman.
On the average day, my pain level is a 6. That's just the average. On a moderate day, it rises to a 7. On a bad day, I walk around wanting to weep from pain, so exhausted from pain, I can barely keep going. I'm exhausted. Yet because of the way my body works, "the worst pain I can imagine," is far worse than a 10, it's more like a 15. I am worn to a nub.
I took opioids for years, to ease this pain, and due to a hiccup with my insurance, I stopped taking them. I did the withdrawals and never looked back. I do not desire to take them again due to the social costs--being treated like a junkie should I DARE to seek medical treatment, even though I have NEVER abused ANY medication EVER and never would. I was scrupulously careful. Yet ANY person who takes opioids is suspect. Even PAST treatment makes you suspect. Even being ALLERGIC to MOST forms of opioids makes me suspect, for crissakes!
But I am in so much pain, I cannot function. I can barely dress myself. I cannot do my household chores. Working is a distant--happy--memory. I wake unrested. I cannot sleep on my right side. I avoid standing, sitting, lying, or walking, for too long.
I don't have cancer. I'm not dying or terminal. I'm in pain. It's not going to go away.
15
@Dejah, My heart goes out to you. I know what it is like to never have a Pain-free day, but your level sounds much worse. I love life and this world, so that makes it complicated, because I have no desire to leave. I HATE this "War on Drugs" because it affects those who do not take them for recreation. I hope for a day they come up with a non-high-inducing pain reliever, for you, for me and those that are in pain. I have come to the conclusion that it should be everyones' right to take what they choose. I wish that were the law.
5
New York Times Entry 2
By Jared Garfinkel
What interested most in the times this week was the article “When Patients Need Opioids to Ease the Pain.” This article interested me because it talked about the touchy subject of opioids and their effects. Opioids have been discussed a lot in the news and this article showed what opioids can do. It did this by explaining the experience of a doctor and his patient with a very rare disease.
Dr. Skeres’ patient had been diagnosed with a rare disease. The article states, “He was in his 70s and had a rare variety of a rare cancer: acute lymphocytic leukemia, which affects fewer than 3,000 adults yearly in the United States, along with the more common acute myeloid leukemia.” The cancer would have killed him, and it almost did. Trying to save his patient’s life, Dr. Sekeres decided to preform a special therapy on him. The article states, “In response, we decided on therapy that would try to clobber both leukemias at the same time. The drugs had hit the mark, as the leukemia had disappeared entirely from his blood stream. But they had also missed, taking a whack at his liver and disrupting how his body processed the bile the liver usually makes to help digest food.” The liver is an important part of the human body, and with his in such bad condition, the patient was in an intense amount of pain.
1
I am a senior and I have real fears that with increasing age medications will not be available to me to make my life tolerable. This should not be a one size fits all situation and should I become more incapacitated with pain I won't be able to go out on the street to look for crack or heroin. When these things happen there is always a tendency to throw the baby out with the bathwater. Should I start hoarding medications to ward against future suffering.
8
I broke my back from a war casualty injury in 1974. I was a kid and the doctors' said I would start to feel it when I grew older.
When I turned 50 the pain started. First it was low level and could be treated with ibuprofen and acetaminophen. This worked for a while, but increased dosages of acetaminophen did nothing and ibuprofen gave me a sore throat and upset stomach. After a while I started coughing up blood.
Eventually I was prescribed Oxycodone. It worked. After a while its potency lessened, but if I took even one more pill a day my Rx would expire days before I could renew.
My MD was and is terrified to up my dosage. So, near the end of the month I have to white knuckle it. Hot baths help until you get out of the tub. Sleeping pills are useful to just sleep through the pain. This, I know, is not a good remedy.
I have days where I have to crawl on all fours to get to the toilet. Twice I have passed out at the grocery store because of the pain. So I practically live on pizza because I can have it delivered.
Am I hooked? I don't know and don't care.
14
@MJG. This is a seriously unfair situation. Personally, I would see suicide as an option and would depend on friends to find the necessary medications to facilitate it.
3
@MJG such a sad sad story. I hurt for you. I hate the "war on drugs", because it is hurting those that are in REAL pain. Should our focus not be on eliminating the pain of those with real need and lower the priority of fixing those who use drugs for getting high? Where is the proper focus here? I wish a movement would begin where those that have real pain are seen as more worthy of our time than those wanting to get a high. I would surely join such a movement and wave the flag. As it is, I am in too much pain to start such a movement.
3
I have a rare disease, I share with my mother, grandmother, and others in my family. Unrelenting pain. There is no cure. I took 2 opioids for eight years. I took them exactly as prescribed. Every four hours. At the same time I was moving to a different state, my doctor retired. In my new state, my 1st Dr continued to prescribe my narcotics. Then she moved. And more and more doctors were arrested for illegal prescription practices. And now I cannot find a doctor, either a pain Dr or internist, who will prescribe these medications. In fact, the doctor I was seeing at the time, refused to help me get off of these narcotics. Would not prescribe a single medication to assist in the pain of getting off the drugs. So I had to do it the extremely hard way. Now I’m left with unrelenting pain, I sleep in 2 to 3 hour shifts, if I’m lucky. Now I have severe gastrointestinal problems caused by pain that the strongest of medications does not resolve. I am left eating 6 foods.I’ve lost so much weight, that I am in a fragile state. I understand that there are many people who have become addicted to narcotics in various ways that are not taking medication as directed. The national discussion fails to address people like me Who can’t function without strong drugs. I have inches of medical records that support the finding of my rare disease, made even rarer by the fact that they cannot find another family in the world that carries the exact gene. Doctors are failing me.
15
This article, and many if not most similar articles, focus on the effects of excruciating pain. What is frequently overlooked is the debilitating effects of constant, low-grade pain.
I have worked with my PCP for several years for symptomatic relief of the pain from arthritis, sciatica, and neck/spine problems. We do OTC analgesics, OTC antiinflammatories, muscle relaxants ... and at the end of the day (or most usually, in the middle of the night) there is a low dose of hydrocodone that actually allows me to sleep. Dose hasn't changed in years, and I don't take it any more frequently than several years ago.
And I can actually function the next day.
23
Your body doesn't react well to pain & actually slows recovery because psychologically and biologically, you are focused on dealing with pain and not the cause of the pain. I've read research the distinguishes between people who are dependent of painkillers for medical reasons and those who are addicted to painkillers recreationally. Medically dependent painkiller patients usually have no problem stopping painkiller use once they recover from illness.
As for me, I insist on painkillers after excruciating procedures at my dentist's office, I haven't been refused, but if I were, I'd get another dentist. Still, these painkillers are now doled out stingily--you get 5. (My oral surgeon prescribed 10 & the pharmacy wanted to argue about it!). IN ADDITION, I asked my oral surgeon's assistant to please call it in in advance so that my son could pick it up for me on the way home & he could get back to work quickly. They told me they couldn't do that, that painkiller prescriptions can no longer be called in but must be presented in person.
While I'm all for doctors prescribing opiates more thoughtfully, there's no need to punish everybody who has legitimate needs for strong pain relief. Addicts will find the drugs they need if they are driven to use. Depriving me of pain relief won't solve that problem.
27
@Macktan In my state of Minnesota (at least in Minneapolis), physicians can use an app to send in prescriptions for people who are not able go to the pharmacy themselves. Designated representative(s) of the patient are able to pick up the prescription when their signatures match ones on file.
"Addicts will find the drugs they need if they are driven to use. Depriving me of pain relief won't solve that problem." is my position exactly. Thanks for your comment - I'm so very lucky to have a PCP who agrees as well.
13
@Macktan I believe the new regulations are to discourage the generous prescribing of the past that might find a vulnerable patient. I live with a severe chronic pain patient with no cure at this time. We're fine with the new regulations. What we have a hard time with is those patients being left out of the conversation and the crazy way these things are rolled out so that doctors and pharmacists are afraid of these patients. You rarely hear of patients that are harmed by the fear created with them not clearly separated from the problem of addiction. It would even help you and others if clarity was a constant connection in the proble. Everyone should demand they be part of the conversation and acknowledged in every news or editorial presentation.
3
There is so much publicity about the opioid addicts that people don't know that they are a very small percent of the users. The vast majority use opiates responsibly when they need them and stop using when they don't. The opioid crisis is preventing patients from getting the drugs they need. Patients who use PCA use less than if the drugs are administered on a timed schedule. We should stop focusing on the addicts and focus more on the patients who benefit from these drugs. They shouldn't have to suffer because a small percentage are addicts.
19
@S.L.Yes,it will only happen if you tell your representatives that these patients must be included in every conversation and their needs can not be ignored. Ask them how they will make that happen. Contact every article or news outlet to make sure they acknowledge these patients are in danger without bringing awareness to legitimate patients during every conversation. If you have trouble at pharmacies because they are reluctant to fill presriptions even though you are compliant call the company. Ask them if they are discouraging legitimate patients and ask them to intervene at your local pharmacy if they deny that. Enlist a friend or relative to do this if it's difficult for you to deal with it. It's surprising what can happen if you push back politely. Until severe chronic pain patients are a part of this conversation it's impossible to put your guard down which is also detrimental to someone just trying to survive their chronic pain. Write reporters, commentators and every article that leaves them out of the conversation as well as informing your Representative. Without your Reps being aware laws get written that harm these patients. Politely correct social media comments when they are misinformed and spread misinformation. It's sad that it's necessary but even sadder to let it continue.
5
I've had knee surgery, and too much dental work. I've been through enough opiates to know hydro is better than oxy, and that you taper off when you are done, not cold turkey....still, there are things for which advil or positive mental energy isn't working and you need the hard stuff.
I've also worked with addicts, so know that for a percentage of users, there is a huge downside. I don't discount that.
Still, for most folks, they are a godsend when needed...
17
Thank you, NYT, for this brief report. In a time when all we seem to hear about pain relief is the terrible problem of overprescribing, it's important to hear the other side of the story.
I--and I am far from alone--suffer from chronic, intractible pain, that resulting from a fall that crushed multiple vertebrae seven years ago. There's no cure, no repair possible. A prescription opiod (hydrocodone) lets me get out of bed and function more-or-less normally. Over the past 2-3 years, the number of physicians who will prescribe and pharmacies who will fill have sharply declined. I'm down to one pain clinic, and every time I go in I wonder "Will this be the last?"
I am not an addict. I am dependent on my opiod, in the sense that a diabetic is dependent on his insulin. I have no craving, no urge for more or other. Contrary to the belief of the county sheriff, I don't plan to start heroin.
I--we--understand that something has to be done about America's addiction problem. But please: remember we who have legitimate medical needs.
30
@OldPadre
That's really the part of the puzzle that I don't understand. Most opioid overdoses are not from prescribed medication, but from street drugs. How do average people slip from pain management through prescription drugs to going to a street corner to find heroin? We are doing something really wrong in the area of pain medication for this to happen.
4
@Mike S. They don't. It's a myth created by the Drug War. I used to work with drug/alcohol patients. The only one who said she got addicted because of a pain problem was a doctor who injured her neck in a car accident. But even she was not using street drugs. She was taking so many Tylenol with codeine, I'm surprised the tylenol didn't kill her.
2
I always refuse opiods; however in the case of the yoga instructor, caring and responsible physicians and pharmacists, I can see the need. My need may some day come, but for now, I become enraged when any physician suggests that I be prescribed narcotics. "Oh no, you don't. I will not have this prescription filled" Or, "I will not pay for this prescription; I told the doctor I won't take this stuff."
I do not like to be fooled by brain-numbing, and I do not like what opiods do to the other parts of my body systems. There has to be a better way. Is there research ongoing for alternatives?
1
@ultimateliberal. There are alternatives. I was once prescribed toradol after I fractured a couple of ribs. It's not addictive, produces no euphoria, but the pain subsided allowing me to function.
You're a better man than I because I just refuse to lay in bed wailing and gritting my teeth in pain. I won't do it.
6
@ultimateliberal
please don't get angry when these prescriptions are suggested. Just refuse. That kind of response only makes it harder for the person who genuinely needs the meds, but whose provider is intimidated by responses such as this.
shouldn't happen perhaps, but it does. Please be mindful not to contribute.
6
Cancer is the one diagnosis in which opiates are always justified. That's a given, so it adds little to the actual dilemma of when to prescribe opiates. The same is true for patients on the operating table, although there are procedures where nerve blocks are appropriate.
The controversy is how to treat chronic pain in which there are no objective findings to provide guidelines of progress. Determining just how and when escalating doses are indicated and when narcotics are not effective are difficult to determine. The insurmountable problem for physicians is that pain is subjective and there are very few medications that suppress pain fibers without also producing euphoria. As difficult as it is for physicians to determine, patients also may not separate the need from pain relief from the pleasure of euphoria. This is not to knock euphoria, but euphoria as a medical goal is not something docs are trained to provide.
Whenever possible, I favor local anesthetics. One is lidocaine which can be applied topically by patients as needed. Now that's a drug that only provides pain relief. A Nobel prize to who ever finds a pill that only provides analgesia.
4
@citizen vox
"This is not to knock euphoria, but euphoria as a medical goal is not something docs are trained to provide."
They aren't trained to be concerned about it in any way.
Doctors right now are more concerned with a benign side effect than they are with the primary effect of a drug. They are more concerned with a population they haven't even come into direct contact with than they are treating their own patients. They are more concerned with the guidance law enforcement and the NYTimes is giving them than they are Cochrane reviews and the NEJM.
6
@citizen vox I never felt euphoria in my life. I only felt less pain. We would say that the majority of those who suffer eith chronic intractable we pain would say the same thing. On what studies are you basing your opinion?
Thank you for your comforting words. While I don't have to endure the kind of pain described in your article, I, too, rely on opioids to deal with two different pain conditions and am grateful that my MD is willing to prescribe them. It seems to me that when journalists have written about deaths from opioids, the formulation they are talking about is Oxycontin. I was given this medication by a hospital and it nearly killed me. I questioned the nurse before I took them. It seemed like too many pills for me to be taking. Yes, I was told. This was the prescribed dose. Knowing what lower doses did to me, I was worried. The reason I was given this medication was to allow me to be transferred to a rehab facility in a wheelchair, in a van, two and a half days after a three level fusion of my spine. So, half an hour later, I arrived at the rehab facility with almost no blood pressure. The concerned physician decided to withhold all medications until my blood pressure improved. No Tylenol, no Advil. Nothing. I finally asked a nurse if they could use ice packs to help alleviate the pain. Thankfully, it worked enough to allow me to sleep. But, there are other opioids that do work on pain without all the unfortunate side-effects: good old Hydrocodone. For those of us dealing with chronic pain, it seems cruel to remove the medications that do work, while offering nothing else in its place. It is an issue that needs to be addressed by the medical community.
16
I am able to live a pretty good quality of life with the help of Vicodan three times a day. Without that help life would be excruciating pain. I am thankful for the help. I wish that the critics, detractors, panicked masses would understand what we have is not really an opioid problem - we have a PAIN problem. No one wants to live their life in pain and nobody wants to be addicted to drugs of any kind, what they want is pain relief. Let's turn our attention to solving this universal affliction.
11
It is almost surprising-- given the levels of dysregulated emotion, unreflective practice, patient-focused hostility associated with a lack of empathy for individuals in pain-- that the newest iteration of the Diagnostic and Statistical Manual has not added a category of 'opiophobia' with associated functional impairments.
11
Studies on doctor administered meds for pain relief in the ER almost always show patients are undertreated.
14
I remember my father having his pain meds restricted as he was suffering. He asked for his meds a few hours early only to be told no. He had a feeding tube, could barely speak. Yet was denied comfort as if he was a junky seeking a fix. He was at the point where something was going to kill him soon anyway. The situation made me so angry, mainly because the nurse was SO patronizing, speaking to him like a child who didn't understand the consequence of the drugs. So he sat there in pain thru my visit.
IMO, if someone is to the point where they are in a care situation, and can't actually take the drugs on their own, withholding pain meds seems cruel.
31
I had major dental surgery two weeks ago. Ice helped. But ice alone was insufficient. Ibuprofen could not touch the pain. Vicodin did. Without it, I would have been in utter, incontrolable agony. I took it regularly for four days. Before switching to ibuprofen for another week. No the pain is gone. Opiates have a place.
21
I have been on a low dose of hydrocodone for 10 years to deal with pinched nerves because of compressed vertebrae. There are a lot of people like me who recieve great benefits from opioids with little or no downside. Also this article as written suggests opioids should be used in only the most extreme cases. In the 1990s there was legitimate concern about how. millions suffered from lack of access to effective pain medications. How sad that the greed of so many pharmaceutical companies and doctors caused an epidemic that resulted in many people not getting the relief they desperately need.
23
I am a hospitalist at a teaching institution. Dr. Sekeres, your example of treating a cancer patient with opioids is an important one. However, there is also a huge number of patients in this country who have real, chronic noncancer pain who are also suffering because they can no longer get access to opioids. I have seen patients with chronic injuries from multiple gunshot wounds, inoperable necrotic hips, and other painful conditions who have great difficulty getting opioids. I see my residents often trying to treat these patients with Tylenol and Motrin, which are great painkillers, but probably insufficient in these cases. I have even heard some residents explain that, "well in Europe you just get Tylenol and hot tea" as justification for not adequately treating pain.
As doctors we need to use the tools available to us to help our patients. Sometimes, that tool might be an opioid. There are certain patients I recall that have had obvious opioid abuse issues, and there are some conditions like fibromyalgia where I really doubt opioids can have much effect, but if there is a miserable patient in front of me and I reasonably feel that they are not drug-seeking, I will use these drugs judiciously. I tend to use morphine, because anecdotally for patients it seems to carry more "seriousness" compared to "friendlier" and more familiar sounding drugs like oxycodone or Dilaudid.
I do worry that we have swung too far in the other direction too quickly.
43
@jason
As is typical in this country, we blow up the house to get rid of a bed bug infestation.
10
I'm allergic to two of the strongest non-opioid painkillers, so having opiods after four shoulder surgeries was necessary, nonetheless I couldn't wait to get off them. They made me feel like crap coming off them, I guess that's why folks stay on them so long.
2
A client of mine was in hospice recently. The hospice nurse told me that it was even getting more difficult for them to prescribe the combinations of opioids that could successfully control pain. My client had been on methadone and hydrocodone for years—it was the only way to Even begin to keep her comfortable. What kind of insanity is it where we start trying to limit medications to people who are actively dying in hospice? Why? So they can die undetected? This is heartless medical treatment
34
As someone who was maintained on opioid medications for nearly 8 years--and withdrew with absolutely no ill further desire to seek such meds--this is outrageous, cruel, and inhuman. The fear of addiction is overwrought NONSENSE.
Addiction is psychological. Dependence is physical. If you take Opioids too long, your body WILL become dependent--because that's how opioids work--and when you go off the meds, you must do so under the care of a doctor. If you do not have other addictions, then there is relatively little chance that you are going to suddenly and MAGICALLY become addicted to opioids when you are no longer in serious, terrible, and intractable pain. Doctors now this very well. The fear, uncertainty, and doubt pervading the US which is causing doctors to prescribe 6 pills a whopping DAY AND A HALF of pain relief where they used to prescribe a week's worth, for pain which actually lasts a WEEK, is nothing more then fear created by the Federal government, which is leaving people in agony with insufficient pain relief for unbelievable pain.
Pain patients and particularly chronic pain patients are NOT the people becoming addicted to opioids. The studies are VERY clear on this. It's well know, well shown, and the poor man in this article suffered FOR NOTHING. Nothing but lawmakers and drug enforcement's ignorance.
The best pain management clinic in the local area closed because of the Federal Government's insane jeremiad against pain doctors. It MUST STOP.
36
Thank you for writing this article. The opioid epidemic is real, but suffering of many like myself is continuing. I hope that those that created this nightmare for those of us who would not be here today, if for not the medication that makes life a lot more manageable. I hope that because of Drs like you, our voices will be heard!
Thank you
27
Last year as an Inpatient at Memorial Sloan Kettering for Myeloma on my spine I fought tooth and nail the pain management team. Kept telling them I didn’t want to end up on the Dr. Phil show. Finally I broke down and went on extended release oxi and breakthru pain oxi. Thank God it’s out their for cancer patients. Got off if it after one month without any issues. Used it again after hip surgery for cancer and it’s their for pain. Don’t be scared of getting addicted. Good pain mgt team will help you thru it. I never leave home without my bottle just in case my lesions act up. I succumbed to it and it’s in my zipper compartment with my lipstick! Life’s too hard to sweat it! If you need it take it!
Thank you to all my pain team at MSK......
19
It is inappropriate for government officials, non-physicians, to interfere in the practice of medicine. It is scandalous that even a single human being be deprived of appropriately controlled medication for any disease or symptom, principally of pain relief. It is the prime example of the trashing of a fundamental Constitutional right, as well as a callous disregard of a universal human right.
The opioid addiction problem in this country is fueled by the rapacious criminal drug dealing industry, which has deflected, by the infusion of massive sums, and by racially targeted propaganda, attention formerly directed to itself, a situation which it undoubtedly delights in. It is fueled by the cannabis dealers, who provide, with legislative collusion, the key for youth
to the relentless prison of addiction and death.
All legislators voting on this subject, and all high level appointees should be compelled, on pain of imprisonment, fully to disclose any and all potentially addicting substances which they are personally using, and that disclosure be verified by periodic invasive drug testing.
I would start with the Congress, then the Senate, then the Cabinet, and the both the President and Vice President, simply as a matter of periodic routine, say monthly.
Testing would include daily blood alcohol, weekly cocaine, and monthly cannabis testing levels.
Testing might be expanded to include all family members as well, particularly those receiving treatment for pain.
No?
17
@Arthur Taub MD PhD I agree wholeheartedly. Here and in other areas, such as the ENTIRE SPECTRUM of women's reproductive health care, government and legislators NEED TO BUTT OUT!
As an example MA Gov. Charley Baker, of whom I have some respect, in other areas, inveigles against the opioid 'epidemic.'
Hard to disagree that drug companies & others, in pursuit of profit, have contributed to life-altering/fatal misuse of drugs in the US & elsewhere.
Many problems impacting the lives of those who live south of the U.S.'s borders, are caused by insatiable demand of US 'consumers,' for one or another kind of illegal/illicit drugs.
Misuse of drugs causes problems everywhere.
HOWEVER...
I recall hearing a radio broadcast on one of Boston's NPR radio states, perhaps, circa 2013-2014, or so.
Gov. Baker's son had broken his arm, badly if I recall correctly, not a simple fracture, with, as I recall, real potential for a considerable amount of life-altering pain involved.
Gov. Baker 'volunteered' that he would, & perhaps, did, counsel his adult son to NOT TAKE any physician-prescribed opiod medications, which might have been prescribed to alleviate his significant pain.
Gov. said that he would counsel his son to, instead, take large doses of ibuprofen. I 'imagine' the Gov., who is neither a doctor, nor any other kind of health care professional, 'meant well.'
HOWEVER...
Ibuprofen can damage liver/other organs.
Perhaps the Gov. might leave health care to the professionals...
13
I've always believed there are far worse things than addiction for intractable pain.
19
Margie I just posted something similar! Of this cancer gal so agrees!
10
A good friend developed severe sciatica in the mid 90s. I remember him talking about something called "Oxy's", and how his doctor prescribed them like candy. Have no idea whether he became addicted, but that's of little importance.
Addiction is a far better result than chronic, excruciating, life-destroying pain. (Fortunately, I have been spared that in my 67 years, but things change). Where we are now is an outrage. Politics doesn't enter into this. I am a political conservative and think this is lunacy.
21
I get so disgusted each time I read or hear another news story about how bad opioids are. It was refreshing to read this article (and the reader comments) defending opioids for the many patients who use them responsibly to improve their quality of life. I have several immune system disorders, including rheumatoid arthritis. I was first prescribed hydrocodone by my rheumatologist 15 years ago. I use it sparingly, typically just one pill on the days when I need it. (My current script was written two months ago and I have taken 5 pills during that time.) Knowing that I have something available to me when the pain is intense enough to interfere with activities of daily living gives me great piece of mind. I have had both hips and knees replaced as well as cervical and lumbar fusions in the last 10 years, which meant that I was prescribed larger amounts of opioids post-op. Each time, my doctors and I tapered me off the pain meds. Sadly, I know a number of people who need major surgery, but have declined it, thinking they will become addicted to opioids after the surgery. I understand the seriousness of the opiod addiction problem, but the stigma attached to any use of opioids is doing undo harm to patients who are afraid to use them because of all the opioid horror stories.
30
I had a patient who choose suicide rather than try to live in the horrific torture of unrelenting pain. She had a similar condition to this man only there was no known cause at the time, no cure and so she was facing a feeding tube as the only way to stay alive.
She was 38 and would have had to spend her life in a nursing home. She had gone through all her resources and her doctors where now her only support . She had been a professional with a good job. I secretly agreed with her choice , very sadly she could not get the level of narcotics she needed in order to maybe to tolerate life a little longer. Her doctor would have risked his license to prescribe at the dose she needed though he was going to do it anyway when she choose to give it up.
28
The whole issue of opiates used to control chronic and/or acute pain is completely politicized, and there are no real advocates for people who suffer from high or excruciating levels of pain. The FDA can search out a doctor's office with no search warrant. The DOJ in California can harass and threaten a doctor who is conscientiously trying to manage a patient's pain and suffering. A pharmacist can refuse to fill a legitimate prescription. Not too long ago, pain was considered a condition that needs to be medically managed. Compassionate doctors are being pressured and threatened in this one-sided political environment. This one-size-fits-all approach puts patients and their families in a helpless position. And regretfully, no politician anywhere has stood up to this injustice.
46
Eight years ago I was treated for head and neck cancer. Mucositis is a very common side effect of the radiation which most of us get to kill the cancer. And there is often also be pain from surgery or the combination. Opioids are often the only thing that will relieve the pain.
The pain and swallowing difficulties from the radiation sometimes make eating impossible; we almost all lose a lot of weight.
I was fortunate in that I didn't have much mucositis and other pain did not last very long. But when I did have it, oxycodone was a wonderful help. My radiation oncologist explained, as did Dr. Sekeres, that using it as prescribed would not get me "hooked." And it did not cause euphoria either, just the relaxation that comes from not hurting.
Cancer pain is a common use of these drugs as intended. I have a friend whose husband is disabled and had been on morphine for years. Then the government said it would no longer allow it, and he had to switch to non-opioid medication to deal with his chronic pain. They were really worried, skeptical that anything else could work as well. But they were pleasantly surprised that not only does the alternative work as well, but he is more alert, has fewer GI problems, and feels better overall.
As with antibiotics, doctors now have to learn the appropriate uses of these drugs, and patients have to be OK with trusting their doctors.
14
@Susan That's the problem: many American CPP can't trust their doctors. Doc's are tapering their opioids to doses that leave them in debilitating pain, or even stopping them entirely, sometimes cold turkey!
13
I am a chronic pain patient and without history and details the pain is in my cranial nerves in my face. My doctors didn’t believe me until I a twitch came on in the left side of my face. The joke is even with methadone my pain is 24 7 but it is better than the alternative. I have been on all kinds of non opioids and none worked.
So personally I would prefer all NON DOCTORS and Governor CUMBO to get out of my doctors office. Thank you for not caring because now I am being told I have to get off opioids. I hoped to your higher power that you never have pain like i have or thousands of others in worst cases. It wasn’t my choice to be in pain. I am not sure who Made you god or the government. But just wait until you or your love one really needs help and they tell you no sorry your a druggy and then you might have to choice between death or a misery so bad . Also oxy is so expensive I had no choice but methadone so I am not sure who can afford these drugs. Anyways why can’t all you caring people focus on alcohol drinkers or gun murders. Why chronic pain patients?
7
I'm confused about something.
Many comments say doctors now refuse to prescribe opioids.
If this is true then who is writing the almost 200 million opioid prescriptions written each year in this country.
6
@Steve Those of us who remember the oath we took, despite the over-reach of regulatory agencies who practice medicine without a license.
16
Thank you NYT for publishing this. I suffer from chronic pain induced by a herniated disk. At times it feels like someone is driving a railroad spike into my upper leg and groin areas. At other times, the pain shoots down the entire leg to the point where a good night’s sleep is just not possible without some relief. A low dose of an opioid was prescribed by my doctor only after I had exhausted all other options. I use it with great care and full awareness of the potential issues...and my doctor and I are satisfied with the results.
When I tried to get my latest refill, a 30-day supply, I was told that my insurance company, a major provider in Southern California, now requires my doctor to justify why I need more than a 7 day supply once every 90 days. It’s shameful that so many people with legitimate need are getting caught in this political crossfire, and equally shameful that my insurance company is questioning my doctor’s carefully considered diagnosis.
I sincerely hope that our politicians can step up and help those of us who try to responsibly manage our chronic pain.
48
@Paul
I suffered from chronic pain in my entire left leg which led to using a cane, then a walker. Back X-rays indicated problems in the discs. Finally I was diagnosed with a degenerated hip joint which was replaced. All of the pain has gone away.
4
This is why drug companies developed these miracle drugs decades ago; shame on the deplorables for abusing them...
9
This. These medicines flooded my state, almost as easily available as booze and cigs. The latter two have been available all my life but I don’t ab/use them. Just because something’s available doesn’t mean it has to become your favorite toy. These addicts who got hooked because they were bored and decided to see what was in Granmaw’s medicine cabinet — well, I have no mercy.
Thank you for showing compassion to pain patients and for doctors who are so harshly scrutinized for providing needed prescriptions. If opiates are criminalized then what is the alternative? So far we have very few options. If you love someone with a chronic pain condition, the war on opiates leaves them out in the cold. and it’s frightening to know that suicides will rise if no assistance is given.
“Pain is a more terrible lord than death itself”-Tennyson
30
@MR as one of those patients - someone who has rare, medically marginalized diseases (a concept from the academic work of Carmen Cutler) of Ehlers Danlos, Hypokalemic Periodic Paralysis, Post Orthostatic Tachycardia Syndrome, Hashimoto’s, Gastroparesis, Mast Cell Activation Syndrome, Myaglic Encephalomyelitis, Turner’s, congenital heart defects and being in current workup for Sjogren’s, Lupus, and other autoimmune disorders that are highly co-morbid with EDS, thank you.
Because I was young when it first became a huge life disruption (around 10-12, my body couldn’t cope with the weight change and because of my missing chromosome I had an abnormal puberty), docs didn’t believe me and shoved me aside. In medicine, we say, “If you hear hoofbeats, think horse, not zebra,” something I learned as a practitioner, too. But for those of us who ARE zebras, especially at a young age, seeking relief while still in diagnostics, or just seeking diagnostics at all, is PUNISHING.
Keep this in mind: I’m still not fully diagnosed and I’ve been trying for 19 years. It took me 15 before I got the first one, 18 before my “main pain diagnosis.” It didn’t stop me from dislocating my spine, including L4 and L5, and my cervical spine, many times.
Even people who aren’t diagnosed have very real pain. And when I’m not on opioids, I literally wish for death. I have PTSD from docs not believing me, and it’s horrifying. Don’t stigmatize people for their needs.
28
I wonder what would happen if this leukemia patient happened to be one of the valiant officers who has made fighting the War on Opioids his Mission in Life. If such an officer were in excruciating pain, would he succumb to the easy temptation of the Enemy, or choose unspeakable suffering and perhaps martyrdom in the Holy Name of the War to which he has devoted his life?
Alternatively, suppose the patient were the officer's son. Would the officer allow the Enemy to ease the suffering, or insist on letting his son suffer rather than become yet another victim? More generally, is it perhaps possible for officers to let expert doctors consider what is appropriate for patients rather than reflexively fighting the Enemy through knee-jerk administrative or criminal sanctions?
I'm well aware that Zero Tolerance is the easiest approach to a wide array of problems, as it's completely mindless and allows even officials with limited intelligence to pretend they're doing something. But inevitably a Zero Tolerance approach produces stupidity and injustice at best, and needless suffering at worse. There must be a better way.
24
I have a degenerative lumbar and cervical disc disorder. I was born with it, as were my father and his siblings; farther back I don't know about.
This was diagnosed in 1971, during my first prolonged episode of disabling pain as an adult. Although I was barely able to walk, and could find no position to relieve pain, I was never given any opioids during nearly a decade of supposed treatment.
I was prescribed a variety of drugs, but eventually settled on aspirin, 6 to 12 per day, which led to GERD problems after several years.
Finally, during the oh-so-horrible years of effective pain management, I was prescribed codeine, and at some point my PCP realized I was a "safe" patient, he prescribed codeine in 100 counts, which always lasted much longer than expected.
Not only does it relieve the pain, when necessary, but perhaps even more important, having it available relieves anxiety about pain...consequently, I use it less often, because I know it's always available if I need it.
However, I now have some anxiety about regulations forcing my PCP to restrict or cut me off. Guess I'll find out about that fairly soon.
24
@Byard Pidgeon I have similar fears. I spend more time finding a pain practitioner than I do on finding primary care or specialists at times, because I now have PTSD from forced pain, a yelling doctor (that one was just for asking for a wheelchair, no pain meds), forced tapers, and constantly, constantly, constantly being gaslit about why I “don’t need the meds.”
I sat in a room with a doctor while my L4 vertebrae was dislocated, a room to which I had walked, unsure of why I was so exhausted and stiff and painful, and told him I was trying to do it without the meds but the neurological strain was putting me into 8 hour, continuous anxiety attacks instead of sleeping (I have dysautonomia so my body can’t manage fight or flight/rest and digest well). I couldn’t digest, I wasn’t able to keep any food down... every symptom was worse.
All this and I’ve never abused narcotics, not in what is now 2 decades of use. I recently tested and found out I’m genetically resistant to narcotics. Not only are they less effective on me, but I’m that much less likely to abuse or become addicted.
Being treated like a criminal for daring to think our pain matters sucks, doesn’t it?
I’m so sorry you go through this. I would never wish it upon anyone.
13
Chronic pain patients should not be subjected to fearful doctors, not prescribing opiates because they end up on a warning list from the FDA and/or DEA. This is not practicing medicine for the good of the patient but for the good of themselves. Not everyone is prone to addiction and the opioid crisis did not start from pain patients. Treat the patient for pain as well as provide treatment for addicts.
28
@Cara I’d highly recommend everyone ask their practitioners about genetic testing for opioid resistance, neurotransmitter health, and the MTHFR gene.
4
I am more concerned about the patients in extreme pain that are denied opioids than I am those that abuse them.
81
Bless you.
14
@JenniferI’m thankful every single day for people like you. I might never have ended up a wheelchair user if everyone thought like you do.
9
"Some patients genuinely need powerful painkillers to make their excruciating existence at least somewhat tolerable."
Ya think?
43
It is heartbreaking, immoral, and unethical -- but oddly not criminal -- to let people suffer so badly when relief is available.
43
I'm so sick of the govt and doctors making ppl suffer from excruciating pain because one family took the US for a con job on opioids. Not everyone gets addicted. This is a sweet story like it should be when ppl are in pain. The govt and medical profession should have found something to replace the fentanyl before taking ppl off pain meds.
31
The real fentanyl is used everyday in hospitals and in patch form that delivers micrograms per hour. The street synthetic from the cartels is what killed people.
16
@ElleJ yeah I’ve been on fentanyl at 50mcg around the clock legally and it is a wonderful drug when used appropriately for people who don’t benefit as much from other opiates.
6
People are posting their chronic pain stories and i have mine. But I won't bore you with it.
I have a sane pain management dr that I see every 3 months who has been willing to do radiofrequency ablation for back pain and sciatica with good results. I also take 1 - 5 mg hydrocodone daily which helps but doesn't eliminate the pain. My choice to keep dosage low. Don't tolerate steroids well (though I've tried back injections) or ibuprofen, don't drink alcohol.
Days without sciatica are a party!
My mantra is "pain management" not
"pain elimination".
15
I live with severe 24/7 chronic pain. Oxycodone is the sweet spot for me, in terms of damping down my pain. Other stronger drugs don’t do the same. Like fentanyl or dilaudid. They just make me uncomfortable stoned, but don’t help the pain.
I used to be able to get oxycodone, then the government somehow took over and no doctor these days will prescribe opiates.
Every single day I have to determine if today is finally the day I decide to commit suicide because the pain is intolerable. I know one day I will finally say, that’s it. Later.
42
I totally understand where you are coming from. I have CRPS and through I’ve moved from NYC I’ve had to keep the same pain management doctor because I couldn’t find another in NJ to prescribe my medications (methadone and oxycodone). There are doctors out there that treat the patient instead of the crisis but you have to look hard for them and most of them are in major cities. It’s a struggle to find them though, that’s for sure. I hope you find a doctor that will help you.
16
I understand but stay strong in your spirit.
9
After surviving an assault after semi-successful surgery to repair the damage, I then suffered additional injury after being injured in a car accident, I ended up in a wheelchair with constant chronic pain. I have had to use opioids for several years. Without availability, I would be in agony.
27
It doesn't take a renowned physician to tell me what I've seen in my own life, what's common sense - this new war on drugs is turning into a war against pain relief for those who legitimately need it. We need reasonable policies, not just a common story.
My father died of the same disease at the same age, within weeks of diagnosis. He refused painkillers for chemo side effects, but needed them to deal with amphotericin B. I'm glad this was before we declared war on painkillers and that he had comfort.
37
A dear friend suffers from a movement disorder that attacks him multiple times a day and extreme insomnia, among other ailments/chronic pain. The only thing that gives him any relief is oxycodone. If it was stopped, he'd be a suicide within a month. And while many hearts would break because he is dearly loved, all would understand.
I really hope sanity reigns in the government and people who really need it and are under close supervision from a doctor, can continue to get it.
32
Everyone (physicians, pharmacists, law enforcement, licensing boards, & hospitals) would benefit by requiring all licensed physicians to receive mandatory pain management and opioid pharmacology training before being permitted to prescribe controlled substances (having a DEA number does not guarantee that a prescriber is competent to prescribe opioids). Requiring each opioid Rx to include a patient diagnosis would be very helpful. Sadly, physicians who are most experienced and competent in using opioids are the ones upon which the DEA most often focuses their attention. Most regulatory bodies and law enforcement agencies only hear of opioid abuse, diversion and addiction stories; they almost never learn about the many pain patients that have had their lives restored by the appropriate and judicious use of opioids as part of their pain management regimen.
22
@M.A. Heinzmann
You are right. But this should not be a Medical decision. Doctors should tell us the effects and then bow out. This should not be a Legal decision. All painkillers should be legal, using the alcohol model. Will some people become codeine addicts? Probably, but so what? We accept that some people become alcoholics, and help them, not arrest them or shun them.
This should be only a practical issue. Will narcotics work, and how do I best use them?
Opiates are among the cheapest drugs available. If legal, drug cartels disappear instantly. Remember Prohibition?
9
I do not have cancer, at least not yet. I am bone on bone in one knee and have painful arthritis throughout my skeletal frame. There are also inoperable bone spurs in my spine. The VA has had me on opioids for eight years. They recently cut my dosages to a level that makes suicide a much more attractive option than living in intense and debilitating daily pain. If not for my family and beliefs I would already have abandon the struggle to deal with the pain. A large man they have me on the same dose they would allow a small women with the same maladies. They have told me that getti ng cancer is the only way to restore my former dosage which did not completely alleviate my pain but made the activities of daily live bearable. If only common sense could prevent the pendulum from swing so far out of bounds...
60
@DCreamer
I hope THC or CBD works for you. Worth trying.
6
@DCreamer
"A large man they have me on the same dose they would allow a small women with the same maladies. "
Opioids are not weight based.
This is an interesting article, and it points out very real casualties in the fallout from the opiod crisis. The first is that in some cases, people who genuinely need the advanced pain relief of opiod based drugs have a hard time getting them, or as with the patient in question, people assume you take an opiod and you are going to end up hooked on the drugs and then left to fend for yourself.
It is sad, and it might have been avoidable, the real problem is that opiods were overprescribed and also that the companies marketing them basically lied about the risks at the levels they were recommending be prescribed, not to mention that they incentivized doctors to prescribe the medication.Add that to a lack of affordable addiction treatment and it isnt' hard to see where the crisis came from. And before someone tell me it isn't true they were overprescribed, they were, I have had several relatively minor procedures involving dental procedures and things like cleaning my sinuses out, or after getting stitches after gashing my hand, and I was given prescriptions for drugs like Oxycontin and the like (I never filled them, I used a basic NSAID and I was fine). Obviously someone of Chemo is likely to need heavy duty drugs, but for a sprained ankle?
The problem of course is that the opiod manufacturers make less money when the product is restricted, they of course could raise the cost of the pills, but then that could lead to backlash.
3
No, the best plan the cdc has is to turn true suffers of chronic pain into suicides or new customers for drug dealers. I am so glad for you, really, that you can take nsaids and get relief. You are blessed. I do Agree they over prescribed to a lot of people. There were also medical workers that consciously dealt drugs out of their offices. But what the cdc has done is leaving so many of us the unfortunate suffering area to pick between those two choices.
32
A wonderful example of humane, evidence-based care that all -- docs, patients, other health care professionals and policy-makers should keep front & center.
18
I'm 73. I suffer from chronic neck and upper back pain. Eight years ago, going through a particularly rough patch, I became terribly ill, despondent. Every morning I'd calculate the value of the day ahead according to my goal of beating the two year suicide clause in a recently purchased life insurance policy. An old friend got wind of this and pushed me to try one of her legally prescribed 5mg hydrocodone. The difference was immediate. Three to four hours a day of relief. Enough to have pleasant dinner with my wife. Subsequently, I got a prescription for same from my family doctor. A year later, two a day. No more counting the days to the end of my life. Then the opioid crisis. To continue this script, I had to drive over an hour to a 'pain clinic', with their contracts and pill counts, and unannounced urine tests. Very expensive urine screens for over 27 different legal and illegal substances. Rain or shine, every two months my wife took me to the clinic for this dog and pony show. Pity the man or woman who can no longer drive, or has no car. Or has no insurance. These doctors never once examined me. Never once touched me. Never once came out from behind their computers. Never suggested a different approach, these 'pain specialists'. But my bills were over $500 per visit. Then came the scolding over alcohol, the only positive hit on those urine screens...my glass of wine at dinner. At this point I just quit. Rather the back pain than all that madness..
49
Good luck to you, sir, I’ve been thru all you have described and worse.
11
I have been chronically sick and in pain since I was 24 years old. For three years prior, I went to at least ten different doctors, who said it was in my head. I ended up in intensive care dying from blood loss and in shock. I was diagnosed with serious Crohn’s disease. I cannot begin to say what an ugly and painful disease this is, but thankfully, I had a wonderful doctor. Painful fistula, requiring surgery were a nightmare I couldn’t imagine. I was on high doses of steroids along with whatever pain meds would help. I would have killed myself without them. They were also useful to slow a system down that 20 Imodium couldn’t touch. Twenty-six years later, still having the disease, but able to control it after many years, I found out that my back had lost two discs and my spine had sacralized into the sacrum. Nerves were blocked in my leg. After consulting three neurosurgeons, who all discouraged surgery because it could very well turn out to cause even more pain, even if a good result was attained. I had to go on disability and was in agonizing pain. I am in my 60’s and have been able to take care of myself, having been on a fentanyl patch for 15 years achieving at least a life that wasn’t totally disabling. Now after being on oxicodone, codiene, opium tincture and this patch that truly saved my life and treated the Crohn’s, at the same time, after 40 years, I cannot find a pain doctor who will treat me in ct. withdrawals are unbearable and I have to crawl. Help
37
@ElleJ I am very sorry that you aren't able to find a Doctor who will offer you the help you need. Your pain and cruel medical mis-management is not uncommon since the "opioid crises" began. Who suffers? It seems as if the easiest way to deal with patients is to just deny all of them the drug that will relieve their pain rather than spend the necessary time to properly access the patient's condition. Further, many doctors don't want to deal with the "rules" of prescribing; they don't want to take the time or a risk that may get them in trouble. I don't believe that a doctor who denies relief for a patient has ever truly been in pain themselves. In fact, a doctor once told me that he never understood the need for pain medication until he suffered a broken leg. I hope you can find the help you need to ease your pain which would require a decent, caring Physician or Physician's Assistant. Keep trying please.
14
@ElleJ. My God! This is a complete travesty in a country in which the pols shout about “The best healthcare in the world.” Can’t someone help this person? NYT?
9
You are so right. Thank you for your support. It means a lot, really.
6
Whoa! What message is being sent by this anecdote??? And it's only half an anecdote. We don't find out whether the patient gets released with a prescription for oxy, and if so, if he manages to wean himself off the medication. If the patient is willing to endure pain in order to avoid the possibility of addiction, I fail to understand why the doctor would interfere.
I have had six surgeries, and each required a short period of IV opiates followed by approximately two weeks of oxy. I had no problem getting off the oxy, but some people DO appear to have a predisposition to addiction. I know people who have had this problem and suffered serious consequences.
8
@ShenBowen
IF people can live without opiates, they should be offered withdrawal treatment. If they must have the opiates, then give it to them. When it's legal, it's very cheap, and regulated, so no overdose should occur.
trump want to reduce government interference in our lives? Here's a great way to start.
7
America has criminalized pain based on a lie perpetrated by political hypocrisy and public ignorance.
As a 70 year old beneficiary of a relatively small dose of prescribed opioid medication to cope with chronic pain issues my life has been made enormously better thanks to this medication.
However, changes in law have turned my pain into a criminal offense where the pharmacist is my jailer and my doctor a parole office.
Where once I traveled the country knowing I had access to medication, changes in the law now require me to time my travels to be sure not to run out. If I get an unfamiliar pharmacist I am scrutinized as if just released from prison. Asking for a refill a day early is robbing a bank.
While the thousands of people who die from drugs is real the statistics to scare the public is built on a lie. Politicians lump legally prescribed medication together with heroin, methadone, illegally manufactured fentanyl and other opiate drugs to justify a crisis mentality.
The number of people actually overdosing on legally prescribed opiates is relatively small, especially in my age group. It is certainly not the drug crisis politicians have made it out to be.
By comparison, tobacco and alcohol products cause vastly more deaths yet almost anyone can buy both anytime anywhere. So what is the difference besides hypocrisy? Governments get enormous tax revenues from tobacco and alcohol. Essentially they are partners in death. Shame on them all.
69
@zb Yes to this - I am 82 and also in chronic pain from ruined joints and systemic arthritis. I don't have oxycodone, just a lesser prescription pain med. I am not, and never have been an addict of any substance. The pain is unremitting, while my doctor is unresponsive - terrified by the opioid crisis. With the help of now-legal cannabis, I'm enduring - for now.
15
@zb
Not to mention if you try to travel abroad. Legally, I have to keep my medications in their original containers, however doing so means that I have to take them with me in such numbers that I can no longer even have layovers in the UAE, Singapore, and almost the entirety of SE Asia without risking arrest. I've previously lived in China and to this day, literally 4 years after originally seeking to clarify if my medications were legal in China, I haven't been able to get a definitive answer from either the American or Chinese officials! It's utterly absurd!
1
So here is what interests me ... what happened with the patient? Did his mucositis resolve? Did he remain cancer-free? Was he told this could be the side-effect of his treatment? It sounds like he was an in-patient ... was that because of his reaction to chemo?
So many people are pressured into cancer treatment by doctors and well-meaning family members. I am just curious if this is the story of causing the pain and then asking for credit for fixing it.
14
I am a doctor who works with leukemia and lymphoma patients, and this a predictable response to certain aggressive chemotherapy regimens. It’s not an allergic reaction, just a side effect, the way nausea and vomiting can be. It gets better when people’s bone marrow recovers from the chemo (as it almost always does, on a fairly - though not completely - predictable schedule). It is standard practice to warn patients about this effect before giving these chemo regimens. It is true that a 70-year-old with AML and ALL has a bad prognosis regardless of the treatment regimen chosen - and a good oncologist will always make this clear before proceeding with treatment.
22
@Harvey
With this type of leukemia, it is chemotherapy or die. No one pressured this patient into therapy, I can assure you.
14
We all die.
The article does not address the seriousness of his patient’s conditions nor the outcome of the treatment. I was contemplating the possibility that the “cure” might not be worth it. And I have seen pressure from doctors and family members to have treatments when the patient is accepting of their fate. I recently read “Anatomy of Hope” and was fuming at the author, preening over his ability to get patients to change their minds about refusing treatment. This is a conversation families need to have. If I say I don’t want treatment, don’t guilt trip me into it.
Of course, back to the article, freedom from pain is so important and should not be avoided for fear of addiction especially for those with a terminal condition.
12
As an Nurse, I observed that when patients are given adequate pain medication, even before a painful procedure, the timing to have the drug on board enhances relief and subdues pain. Once the acute pain subsides, patients know and start to refuse medication.
Chronic pain takes a fine chef of a physician to get the mixture right for a steady state of pain control.
28
A question:
If opioids are the answer to chronic pain, why didn't any studies show a reduction in the number of people suffering from it when the number of opioid prescriptions rapidly rose between 1990 to 2010 or why there haven't been any to show any increase in it with the reduction in the number of opioid prescriptions since then.
If a treatment is effective, there should be a reduction in the number of people suffering from the disorder when it is given and an increase in sufferers when it isn't. Nobody has shown this for opioids.
5
@Steve
Good point. Some of them were taking it to ease Psychological pain. But, so what? People drink to relieve Psychological pain. People starve themselves or overeat to relieve Psychological pain.
These people need therapy, which is unaffordable and unavailable for most people.
Opiates are cheap, and do affordable for people.
People with Psychological pain should have better alternatives, but if opiates are legal and available, most people live for decades that way.
And, of course, here we're talking about physical pain, which is often untreatable by any other method.
3
@Steve Strawman fallacy. No one claimed opioids are "the answer to chronic pain." No one claimed opioids reduce the number of people suffering from pain.
Opioid medication is a tool to mitigate disability associated with certain pain-generating conditions. Imagine mucositis related to cancer treatment, but it never gets better. For 60 years or more.
People with the most common types of chronic pain typically don't benefit much from opioid medication. People with rarer types of chronic pain can benefit, because medication allows them to continue to work and participate in normal daily activities. Before 1999, these people mostly lived their entire lives homebound or institutionalized.
The pain doesn't go away. The number of people suffering from pain doesn't change. But for some (not all) of those people living with pain, normal life becomes possible.
4
@Steve
Opioids don't cure chronic pain; nothing does, thus the word "chronic". They do, however, make it bearable for many of us and let us participate in life, instead of watching from our beds.
10
Obviously we need a much more nuanced discussion about and protocol for these drugs. It's scary and distressing, not to mention wrong, that people who are truly in pain are not getting the medication that will help ease their suffering (and that was created for this purpose I would think) because some people have gotten addicted.
22
Dr. Sekeres sets up a straw man by indicating that there are attempts to deny opioids to patients who require them for the management of cancer related pain.
As a pain management physician myself, I challenge him to cite a single published guideline on the use of opioids that advises against their use for patients with cancer.
As far as getting patients "hooked on pain medications," if Dr. Sekeres treats any patients with chronic, non-cancer pain, he should be concerned about this as studies have shown that as many of 25% patients started on opioids for this form of pain end up abusing them.
Finally, readers shouldn't be left with the idea that opioids are the miracle drugs for the management of mucositis. Of all the types of pain suffered by people with cancer, this is one of the most difficult to treat. And the mouthwashes containing doxepin or lidocaine are often more effective than opioids and without the side effects of opioids. As with so many forms of pain, opioids aren't always the most efficacious.
10
@SteveI. The article makes clear that the mouthwashes, etc., were not helping this particular patient. Readers should beware claims that “as many as 25%” of chronic pain patients “end up abusing them.” Such statements fail to differentiate between types and sources of chronic pain and the many different pain meds available, from hydrocodone to fentanyl and other analogues. Such distortions create fear and help to account for the refusal of some patients to accept analgesics when needed.
15
As a chronic pain patient myself (CRPS) I can tell you that it is nearly impossible at this point to find a physician that will prescribe opioids to a non terminal patient. Guidelines or no guidelines many doctors seem to want no part of dealing with opioids. It makes it incredibly difficult for people who actually need them. I’m very lucky and have a great pain management doctor but if I leave the NYC area I’m terrified I won’t be able to find a physician to continue my care. I’ve tried at least 15 other dugs and had a trial for an implanted stimulator and nothing has been as effective as oxycodone and methadone. Without them I would be unable to stand or walk let alone work. The author may have done a poor job setting up the story, but it is a real story for all of those with pain management issues in the United States.
11
@Steve Cancer patients are treated better than any others. You also get palliative care and in the death with dignity states they also have an out. In my province in Canada, we had an woman with osteoarthritis approved for medical aid in dying. So they are okay now with killing chronic pain patients rather than treating the pain.
2
I commend you for taking the time to address your patient's needs.
18
Thank the author for the topic I doubt change will occur. If you get hit by a truck and experience life changing trauma to head neck jaw shoulder the pain is excruciating without relief. Doctors refuse to treat you right out because it is a car accident and others who will do not consider pain relief charge a ton to do cervical surgery placing metal discs and go home same day. Months later untreated pain is extreme suffering for an entire family children parents a community of people who love the once vital member. Lives ruined all around. If anyone thinks a jaw ripped put a rotator cuff and cervical replacement surgery is a walk in the park take a look at the April NJ Supreme Court decision of this year regarding doctors ability to refuse treatment to personal injury cases. Fault be damned hit from behind huge truck. This is not about me but someone I love . Medical insurance drops out at the same time. No approvals for treatment. Person is young with a family.
16
This article is misleading, because it is true for cancer patients but really not true for many other patients with different ailments. Doctors providing good care have a different standard with opioids when the patient has a cancer diagnosis.
14
Typical American approach to a problem --just hit it with a sledge hammer. I have chronic lower back pain that keeps me from sleeping. I was prescribed hydrocodone about 9 yrs. ago that I use nightly so I can sleep. I never abused it and the physician trusted me. THEN 2 years ago, America and NC freaked out, and I could no longer get a script from my Dr. but had to go to a so-called PAIN clinic, where when they found cannabis in my urine, and promptly told me that the clinic was through with me and no more pain killers. Of course NC is a baby state where medical pot is still illegal. I get a script from a physician out of state who mails me a script, inconvenient for both of us.
Most people who take opioids for pain do not become addicted.
Why should me and other folks who need opioids for pain be punished for the greed of the pharma companies and the distributors and all the people who abusing these drugs.
39
Opioids are important for the management of some forms of chronic pain. I deal with abdominal adhesions that stick my organs together and to the abdominal wall. I am lucky that by following a strict exercise routine I am usually able to keep the pain within manageable levels. When I am going through a period of severe pain, a low dosage of hydrocodone takes the edge off so that I can function. Without it, I would be disabled because at times the pain will make me pass out. If I did not have access I would be afraid to be active because the exercise necessary to keep me going can sometimes cause severe pain.
I do not understand why insurers and physicians do not find the standards and recommendations set forward by the CDC sufficient. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm#recommendations
Physicians should inform patients of the risks associated and have a clear discussion about the physical and psychological aspects of withdrawal. I have been through it after periods during which the pain required daily opioid use. No one ever discussed withdrawal with me. The worst part is the severe anxiety that strikes about 6 weeks after ending use. If you know it is coming you can prepare for it. If not, I can see this as a factor that leads to the development of abuse.
5
I had a surgery 10 years ago, nothing really major. I was beyond lucky to have a great OB-Gyn. My dr believes that we shouldn’t let pain settle, I had morphine ad libitum in the 4/6 hours following the surgery. A nurse checked on me often and asked each time if I was in pain, if I answered yes, I had a “boost”:). When I was released, my dr. gave me 2 “magic pills” and told me to take one as soon as I got home and a second one if I started feeling pain 4 hours after taking the 1st pill (I ended up not needing it). He ordered me to go to bed right away once I got home. I followed his instructions and slept basically 18 hours. The next day, I was totally functional and was able to go back to work the following day. My kids were toddlers are the time and I was able to take care of them as usual. I dread the day my OB-gyn retires!
14
ruefully glad to see this article. there is always the sense that the doctors that be look down on those who use morphine, e al. The worst of it is that the drug companies take full advantage. my monthly prescription cost went from $35.00 to $90.00 a few months ago for no reason and no explanation. I tried to look up the company to protest, but it kept coming back to Behringer Iingleheim (offices in Ridgefield, CT. No answer. How does one fight this monstrosity?
8
I am appalled at the increasing domination of medicine by laypersons. This has been evident in treatments for pain and reproductive problems but is also noticeable in the proliferation of internet resources and poorly done ‘research’ which purport to know more about the individual than the clinician that treats that individual and which interferes accordingly. If anything, anxieties and insecurities related to the overtaking of professional guidance by government and corporate intrusion are bound to make all conditions worse including the experience of pain.
17
I have been to pain clinics where there is not one doctor there or on staff. They won’t treat seriously ill people- I was told they couldn’t treat me—so I suppose their making a lot of money by PAs and NPRs prescribing low doses and charging $300 to $500 per visit. Though I don’t dare ask the cdc or licensing people to do anything, knowing they’ll turn a horrible decision into something even worse. What to do?
4
@Dr. Diane
So you think doctors know everything? How cute.
Try asking your friends about misdiagnoses and mistreatments they've had.
2
Doctors of medicine i.e. ‘medical doctors’ know what they were trained to know - medicine . . . That is not ‘everything’. When people are misdiagnosed or mistreated, there are resources available to take care of that including seeing another doctor. Your email suggests that you think they are supposed to be gods. Because mistakes occur in plumbing does not mean one should hire an auto mechanic to do the plumbing instead.
2
I have lived most of my life in pain. I have had 3 shoulder surgeries and a knee surgery. I no longer remember what it is like to live pain-free. Cancer patients are not the only people who benefit from short or long term opiate therapy. I would find it intolerable to live without medication that eases my pain. (Sometimes I think it is not worth living in my condition because the medication only takes the edge away from the pain.) The opiod epidemic has made my life more difficult. My doctor is essentially undermedicating me because he is afraid to lose his medical license. I have to see him monthly because he does not code the prescription so the pharmacy can dispense refills. If I take more medication than the daily prescribed dosage because some days I am in more pain than others, I risk running out of medication before my scheduled monthly appointment. Also, in NY a pharmacy can fill a new opioid prescription within 7 days before a 30-day supply is exhausted. Yet, my local pharmacy has its own policy: I can only get a new 30-day supply on or after the 28th day since the last prescription was filled. Finally, I have a high-deductible health plan. I have to pay $98 every time I see my doctor. This is no way to live.
36
I am a physician. I communicated with the CDC regarding "recommendations" for opioid prescribing. They acknowledge that the predominant intent is to limit the number of opioids prescribed in order to reduce overdoses.
I have read the recommendations in the entirety. There is an aside, a nod in the direction of individualization of dosing and a goal of returning functionality. But for the CDC, as communicated to me, the goal of the recommendations is to reduce the quantity of opioids prescribed. The CDC is aware that these "recommendations" (really directives) are simplified to the level of fear. The fear is that a physician will be investigated and arrested for prescribing a dose higher than the so-called maximum "recommended" dose. Health care providers have told me as much for their rationale of restricting appropriate quantities of therapeutic medications.
The moralizing attitude of the CDC is perhaps reflective of the right-wing turn of our entire government: from the Fed, to the Justice Department, to tentacles within many branches of our government, even supposedly independent ones.
When political considerations dominate medicine, those who are along for that ride have forfeited the right to be termed professionals.
53
I experienced chronic pain for 3 years before I found a surgeon who would replace one of my hips. I’m greatly thankful for my Primary Dr. prescribing Hydrocodone to help me through that time because Tylenol and Ibuprofen did not help. I kept a record of when and how much I took which gave me and the Dr a graph of what was happening. It supported my need for surgery, which I had 2 months ago. I’m now totally independent of pain meds after tapering. Yes, there are patients like me who need the help of Opioids and who have a profile of not likely getting addicted. Greater research and education for Drs and patients is needed.
34
Thank you Dr. Sekeres for this article. We need to dispell the myth that just because you're prescribed opioids for pain does not mean you'll become an addict.
47
Thank you, Dr. Sekeres, for this. In the uproar about opioid addiction, those responsible folks who really need the pain control are too often forgotten. And the doctors who want to help them are too often hampered by arbitrary rules that make it difficult for them to prescribe the necessary medications.
45
Sometimes I get tired of people who assume I’m an addict just because I take oxycodone for severe chronic pain. The pills don’t make me high, and I take them exactly as prescribed. If I am having a bad day, I don’t take extra pills because I would run out before the end of the month. I’m sure I ‘m physically dependent on them, but I not an addict. I don’t like that have to take pills, but it’s the only way for me to have any semblance of a life.
85
Preach.
This needs to be shouted from the rooftops.
24
You are so right. Every pain doctor, most clinics only have APRs or PAs, I have been to acknowledge I need the medicine and still won’t prescribe any. This epidemic mostly from street heroin mixed with synthetic fentanyl will kill you. But no one dies from a patch when used correctly. It’s horribly unfair to people who have suffered a lifetime, in some case, mine, 40 years of it, never got arrested, worked as much as they could, with no history of abusing meds, who are now shut out completely. It should be malpractice to make us sit and suffer these horrors of withdrawals and relentless pain. People are killing themselves because it’s so bad you can’t live with it. Where are the attorneys?
16
Unfortunately those in a position to regulate opioid use often have inadequate expertise in this subject. Applying black-and-white thinking to a complex and nuanced field does a disservice to the unfortunate pain patient, the actively abusing addict, and everyone else.
Far too few understand that tolerance, physical dependence, psychological dependence, and addiction are all separate things. They may all occur together in a patient but they do not have to and usually do not. Let's stop reacting as if addiction inevitably follows from appropriate pain treatment. It does not.
59
@JF
Unfortunately, far too many physicians have inadequate expertise in this subject, too.
While difficult to admit, physicians, particularly primary care/family medicine physicians, have cause enormous harm by misinterpreting the complex and nuanced aspects of pain management. You didn't learn much about it in med school, or residency, and unless you completed an interventional pain medicine fellowship, chronic opioid therapy is not addressed in advanced specialty training to any degree that confers expertise.
Search for peer-reviewed literature supporting opioid therapy for chronic pain. You'll notice a dearth of information. Perform the same search supporting non-opioid therapies including behavioral change therapy etc. and the same lack of evidence is observed. There's a serious problem that's not being adequately addressed, and arrogance from physicians who think they always know best is not helping.
1
Around the turn of the century, I was diagnosed with sciatica. Over a couple of weeks, it got so bad that I was unable to sit or stand without intense, knee-buckling pain. I had to drag myself into the tub to relieve myself, and my then girlfriend had to clean up after me.
I was scheduled to have surgery three months after that diagnosis. Until then, I spent twenty-four hours a day reclined in a very particular way on the couch, otherwise I was in excruciating pain.
I was assigned a pain management doctor who prescribed opiates. Had he not, chances are fair to middling that I wouldn't be here today. Yeah, I would have seriously contemplated suicide.
That's one thing to note about chronic pain; it's not just about the pain itself, but the staggering emotional effect it has. It consumed my life, and affected the lives of friends and loved ones.
The doctor was careful to rotate drugs to avoid a dependency on any one of them.
After the surgery, I was weened off the drugs and really didn't suffer a lingering desire for them.
52
One of the hardest things for we Americans to accept is that addiction is not something that "happens to" people. Addiction is something that people do to themselves.
20
@Stevie Well that’s just silly and an underwhelming response to your understanding of addiction. Regardless, sometimes people have to chose between the lesser of two evils.
8
@Stevie
Harvard Medical School has a free online course on addiction. It would increase your understanding of this complex multifactorial issue, which crosses the domains of genetics, psychiatry, social circumstances and biology. No one chooses to become "addicted". It is a complex interaction of many immutable factors. Harvard's course is excellent in that it emphasizes compassion for every patient.
3
I am tired of the “old” CDC Guidelines being used as a weapon by pharmacies, insurance companies and law enforcement against patients in pain. I deal with this issue every day. My message to those that use the Guidelines against patients: read them and start with the title and purpose. The Guidelines were drafted to address opioid use in CHRONIC NON-CANCER PAIN- Not acute pain, I.e. post-operative pain, trauma pain, etc. and not cancer pain and palliative care.
2019 The CDC has walked back the Guidelines. Read the updates. The authors state that the Guidelines were never intended to be used by pharmacies, Insurance’s companies and law enforcement as hard limits. The Guidelines were intended to foster discussions between provider and patient regarding the use of opioids for chronic non-cancer pain.
2019 The FDA issued a statement regarding the Guidelines and patient harms related to their misuse.
2019 Health and Human Services hhs.gov issued a draft model pain policy discussing patient harm related to misuse of the Guidelines.
Everyday I hear non-evidenced based reasons for denying pain medications to patients who need them to function. If we are going to deny a patient a medication for which there is an underlying medical justification and for which there is a risk that the denial will result in patient harm, i.e. suicide, using street drugs, poor outcomes following surgery, etc., then the least we can do as professionals is to read and follow evidenced-based protocols.
66
In a completely unrelated discussion in an unrelated field today, a coworker spoke of the distinction between guidelines, regulations, and laws. There are a lot of people orchestrating “compliance” who don’t understand or recognize the distinction, with the result that they apply a strict enforcement approach regardless of the details.
Guidelines that are meant to be flexible are no longer allowed to be applied flexibly; regulations that fall short of law are no longer allowed to be questioned, challenged, or interpreted rationally; and laws - well, there aren’t as many as those attempting to manage the operating environment seem to believe.
This article, and particularly the testimonial comments, disturb me. Why are we so unwilling to trust good judgment? Why do we assume no one HAS good judgment?
5
I do hear you dear Doctor and applaud your empathic view of a single case. However, why does health care cost 100% more in this country than the next most expensive country Switzerland, and still wracked by the issues we have? I wish you would also be an agent of change for a system that is broken. Having just repatriated to the United States after living in continental Europe for 20+ years, I am shocked by a medical system in my "home" country, which I find broken. In Germany and Britain, one will commonly find doctors who apply homeopathic and other medical traditions together with allopathic medicine. Pain is also considered part of life and - certainly depending on the diagnosis or situation - a tolerable level is acceptable. As I weave my way through the US system, I find I am offered antibiotics and pain killers of various sorts at the drop of a hat. They would also take the time to talk and listen to what was happening outside of my illness - things such as stress at work, or family issues that might affect health. Here I feel as if I am being "sold" medical treatments constantly. I simply shake my head as I look at both the lifestyle and systemic contributions such as no universal health care, poor food choices, toleration of noise levels, vacation not taken or not enough to truly recover which also contribute to a "health crisis" in the U.S.A.
11
@Alison
This is not a single case. This is a representative case of a frequent occurrence.
Before surgery, I meet with patients, their surgeons, their anesthesiologists and their assigned pharmacist. Together we develop an opioid treatment plan that includes a plan to taper the patient off of opioids. Before scheduled surgery, the patients “train” by participating in weight loss, smoking cessation, nutritional counseling, PT and aqua therapy in order to facilitate the best possible outcome. Co-morbid medical conditions that could impact recovery are identified and treated by a team of specialists. The patient receives extensive education on pain and alternative modalities to control it. The patient is part of decision-making in the opioid taper plan. Most of our patients do very well after surgery with a multi-modal approach, are able to avoid chronic pain, and taper off opioids.
I believe in “fixing what can be fixed”, maximizing function through conditioning, strengthening and stretching, optimizing nutrition, and empowering patients by teaching them methods they can use to decrease their pain themselves. There are many free and low cost things that patients can do to decrease pain: Aqua classes, sauna, yoga, bolstering to relieve low back pain, water walking, topical pain creams and so on.
We use this same team approach for all patients, including chronic pain patients. Opioids are only one tool in the patient’s tool box.
3
@Alison
Our system is a for-profit system run by doctors, hospitals, drug companies and insurance companies. European systems are basically earned state services.
1
@Alison
Where are you finding antibiotics and pain killers offered so freely. In the last several years both of those are rarely offered without much consideration. This is evident in the youngest patients to the elderly among friends and family. Just curious because drs go to great lengths here to make it clear why it’s not routinely offered now. Antibiotics because over treating was making antibiotics less effective and pain meds because of the fear of confusing and changing guidelines interpreted as rules instead of guidelines.
1
I had an industrial accident that resulted in the amputation of half my left ring finger and a bone fusion in the middle finger. As you might imagine, the concentration of nerves in the hand and the amputation resulted in a great deal of pain for several months.
I was concerned about the potential for addiction due to the relatively high and regular doses of oxycodone I was prescribed. I tried to ask my surgeon about the risks and management of a potential dependency, and her response was basically "well, I can take them away" which lead me to not asking anymore.
As it happened, after three months of continuous oxycodone consumption I just stopped one day without any sense of addiction or dependence. It made me question just what the actual addiction risk is and how variable it is among different people.
The other missing element in my prescription pain management was any strategy by my surgeon or her physician's assistant in maximizing my pain relief at minimum opiate consumption -- I had to figure that out on my own. I found that taking meds early in the morning reduced my consumption a lot -- waiting until I was in more pain required more medication to dull the pain which had less duration.
I'm somewhat convinced the my own pain management strategy was beneficial in reducing my addiction risk, but this is obviously not a great idea for people who just follow what's been written on the label. Doctors need to do more coaching on how to use pain meds.
42
Sometimes opiates are all we have to control pain. A combination of liver dysfunction and kidney disease would effectively contraindicate both Tylenol and NSAID type meds. In that situation, we have no other option but opiates. Judicious use in the correct patient population is key...
We should avoid opiates in young healthy adults with transient mild to moderate pain. We should definitely use them where no other class of meds can be given to alleviate pain esp. in cancer and chemo related side effects. To provide the absolute relief from pain offered by opiates to those patients who would otherwise needlessly suffer is part of our Hippocratic oath as physicians.
For years now, mainly due to the really asinine Medicare law linking patient satisfaction to hospital remuneration, hospital administrations have had no choice but to pressure us physicians to push 'pain control' (one of the main causes of poor scores). No pain was to be left untreated lest the patient give us a poor score. Now that the chickens have come home to roost, we are now in the process of depriving deserving patients of the most effective pain relief we can possibly offer at this time.
It's a pity that not much research seems to be on-going on devising equally potent non opiate medications for severe pain...
35
Yes, obviously. Opioids exist primarily as pain medication. That’s why they are developed and it’s almost always why they are prescribed.
My partner lives with chronic pain and the one-size-fits-all, sledgehammer approach of public policy has made her life far, far harder. She can only fill prescriptions under more and more draconian conditions. She can’t change doctors because no new doctor is willing to take on an opioid patient. They have been scared out of doing their jobs by myopic policy and by the overreach that imagines private medical judgements are an appropriate subject for widespread social discussion.
The policies are well meaning and opioid addiction is a real problem. But there is a difference between real medical judgement and public health policy, and doctors need to be free to prescribe as they see fit. Not everything is a social problem. Just for once, could we just stop and think it through? Could we please not use a hammer to do a scalpel’s job?
98
@Mike I'm so sorry for what your partner is going through. I was stable on a regimen of hydrocodone for over 15 years. Now there isn't a doctor in town who will prescribe it to me. I was on the same dose the whole time - never even came close to ODing, always had the right number of pills at pill counts, etc. I was taking an opioid for an off label use, and that was that.
I have yet to find a new medication that controls my anxiety. Social security gives me money because I'm disabled by it, but I still can't get the pills that might make well enough to function. I've tried at least seven (if not more) other anxiety medications, and none of them have worked. So I'm stuck in my house for weeks at a time, because disabling mental pain won't get you your needed medication either.
38
I feel for you and feel it myself every endless day. Chronic pain patients need to come together somehow and fight these draconian rules that are having so many of us embracing suicide. It hasn’t be pointed out in what I read so far, that to have a condition that can’t be operated on or a chronic disease, a patient has no hope. You simply are isolated at home, knowing tomorrow is going to be the same and every other day until you die. It breaks you down every way. I was prescribed different forms of pain meds for forty years by many doctors in many states. Never, never had a problem with addiction. You don’t get high. You only feel less fire and paining burning in every part of your body. But suddenly, you can’t have any more. Why, they don’t want trouble with the feds or state boards. But I won’t have any quality of life. Nothing I can do. Where’s the outrage?
11
@Mike
Doctors aren't free to prescribe opioids as they see fit?
Please supply any laws that prevent doctors from prescribing opioids. Oh, wait I'm wrong. Doctors who have lost their licenses or DEA registration can't prescribe them. But I guess those are the doctors you'd prefer to see.
I realize the dangers of opioids, and that people use them recreationally, but the fact that I had half my breast chopped off and was given 4 pills is just bonkers.
There has to be some respect and trust for those of us older patients who are not addicts and have legitimate pain that Tylenol won’t help.
It has been a trying few years as two more breast operations have followed, and I suffered needlessly.
95
Dear Doctor - your advice about the correct use of opioids is not new. It is advice that was there to follow for decades. Instead, many of your physician colleagues, ignorant of medicinal chemistry, corrupt, incompetent, amoral, or a mixture thereof, took it upon themselves the role of addictive drug dealers, thereby destroying the lives of hundreds of thousands of people.
I would recommend that your column be addressed explicitly to other medical doctors, who, along with the pill pushing pharma dope companies, bear the responsibility for this egregious scandal.
18
@Tom I recently had surgery on my foot and due to a bad doctor in the town before I got here I had to almost beg for pain medication as the doctor was apprehensive about prescribing opioids because of how the feds scrutinize them because of a previous doctor who is now in prison for being a drug dealer but still didn’t get as much time as folks I knew in the 90s who were selling pot. And the pharma salesman never got investigated?
16
@Tom
But that's not what this article is about, clearly you missed the point, and your anger is misplaced.
Anyone that believes that doctors are solely responsible for the opiate epidemic is very short sighted. What the doctor is talking about is the well meaning but heavy handed approach, is limiting doctors ability to be the final arbiter along with the patient. Too often the government uses a shotgun to kill an ant.
3
You’re right but there aren’t many, if any, avenues to address it. So when were are given an opportunity to write in, I will take it even if it’s not exactly the point of the doctor’s fine article. There are so many helpless chronic pain sufferers who can’t even find a doctor to see us, let alone write a prescription. I’ve gone down lists of pain docs and clinics, calling over fifty places and as soon as they hear about your condition, they just say no, we’re not accepting any patients. After forty years of these drugs allowing me to live, I’ve been calling names from insurance and other lists of pain experts 11 months since I moved back to CT. Even the doctor I saw when I previously lived here and saw monthly for two years told me to come back when I had metastatic cancer. Unspeakable cruelty.
5
Doctor education about opioids is also very poor in some cases. There is a TED talk by Travis Rieder describing his mis-trained doctor's attempt to taper him off of opioids after he no longer needed them. Travis description sounds like the doctor basically have him way too little, and too infrequently, such that his doctor basically created months-long acute withdrawals in a situation where he could have gone cold turkey and be done with acute withdrawals in under ten days.
Then there are the many thousands of patients whose doctors don't even attempt a withdrawal, falsely believing that only addicts suffer withdrawal, so they understand up blaming the patient for a situation there doctor created and then exacerbated because of their lack of education.
Stories like his surely terrify patients who have no knowledge about opioids and are completely reliant on a doctor's expertise. When the doctor has no expertise but attemptsa taper anyway, bad things happen. There needs to be more training for all doctors around opioids.
13
@EMath
That is true, but here's the problem, Doctors rely on the pharmacological information that the makers of Oxycontin for example gather during the clinical trial phase of drug testing. Purdue Pharma misled doctors by telling them in the data, that these new long lasting opiates had a lower instance of addiction. Because as the logic went, the doctor would write a prescription for lesser quantity, which would lower the potential for abuse. Because the patient wouldn't have to take a dose of medication every 4-6 hours, taking two 5mg Percocet for example. By prescribing fewer longer lasting pills, the patient wouldn't abuse them. Purdue, omitted that Oxycontin was far more addictive than just percocet.
Sometimes we expect doctors to be experts in all things medical, but they can't be.
7
I agree Purdue was not on the level. But what about the people, kids, who couldn’t wait to crack the protective coating that released only so much an hour and taught their friends to do the same? Some responsibility has to go there. If you took the drug as prescribed and didn’t purposely grind it up and then shoot it on top of that, so many would not have died. Conveniently, that fact doesn’t get publicized. And everyone that truly needs this is shut off. Why do we have to pay for it by suffering endlessly.
5
It is one thing for patients to refuse the pain medications they need due to an unreasonable fear of becoming addicted. It is another thing entirely when patients want those medications, but can't get them because overzealous drug enforcement agencies and prosecutors intimidate doctors, pharmacists, and other medical professionals into underprescribing those medications. If it really is impossible to provide painkillers to those who need them while preventing the abuse of those drugs (and I don't believe that), then we ought to err on the side of providing the painkillers to those who need them. Otherwise, the result is state-sanctioned torture.
62
On top of this, Virginia just changed Gabapentin, a drug many doctors prescribe to help patients avoid more opiates, to a class v drug, making it more complicated for doctors to prescribe it and patients to use it. What the government is doing to chronic pain patients now is shameful. I, like almost chronic pain patients in Virginia, now have to be drug tested to receive tramadol for intermittent use, even though I have no history of drug abuse. It’s demoralizing to be treated like a child or criminal when you are already dealing with health issues. I have tried just about everything to get better. I don’t want to use pills, but I want a decent quality of life if they help me achieve that.
59
@Roxanne Grandis
In the face of thousands of deaths from opioids getting tested should be seen as doing your part in this struggle. No Doctor or government agency should be seen as trying to humiliate you. They are asking everyone including you, to do their part. Of course it's a pain to have to comply with these new rules but if it can help save even a few lives it is worth it.
2
If you use them as prescribed, don’t shoot them or mix with street drugs you don’t die. No one dies from a Percocet every six hours. I resent being treated as a felon.
16
Does anyone think, even for a moment, that the very same folks that work tirelessly to address the "crisis" by making it more and more arduous to get pain relief using opiates will need pain relief at some point in their lives? Will that change their views? Will they then continue to worry about addiction?
There's little doubt that the opiate chemicals are addictive for some people so something has to be done... nonetheless, when others in dire pain suffer needlessly, something has to be done as well.
At the same time, the "illegal" drugs proliferate and thrive... just ask the folks arriving at our border from Central America how the cartels are doing these days.
23
@Taoshum
No, most of the loudest and most influential crusaders against the opiate "crisis" are wealthy and/or influential insiders who will always get a surplus of pain medication when they need it.
I have the strong suspicion that those loudest voices against the use of opiates are mostly moral crusaders who see this as a problem of the boorish and undisciplined masses, not a set of restrictions meant to be applied universally, and especially not to the educated/wealthy elite who have already demonstrated their restraint and self control in obtaining their education and wealth.
21
@Taoshum
It seems true that here in the USA " illegal" opiates started this gigantic wheel to turning grinding up human lives both here and in central America and has lead to the mass migration from the south. We look for the enemy and it is us. To some degree it is always us. It seems that we were born yesterday and have no knowledge of the horrors the British brought to China during the opium wars which were waged by the Brits to force their import of opium from southeast Asia into China. Fortunes were made by the British opium traders.
2
Sorry, not wealthy and in agony.
4
And once again, I will mention that I know from personal experience that cannabis both makes it possible to get the same relief from lower doses of opioids, AND effectively tempers withdrawal symptoms. A coordinated, thoughtful, and non-judgmental policy whereby both substances could be used to help patients with ongoing and severe pain would alleviate a lot of suffering.
And, again, I am no pothead; I don't like the "high" of THC. I just wish it were easier for studies to be done in this country to explore the medical possibilities so that the experiences of those who KNOW it works can't be so easily dismissed as merely anecdotal, and so that strains of marijuana that have ridiculously high amounts of THC snd little-to-no CBD would be more widely available to people trying to manage their pain
14
@NGB--correction...I meant to say that it would be good if strains that contain more equal amounts of THC and CBD be made more readily available.
8
@NGB. I have tried pot and cbd a couple of times with absolutely no pain relief. I know that there is a lot hype that these are miracle cures, but they don’t work for everyone.
10
@Kb, I'm sorry it hasn't worked for you, and I hope you find relief elsewhere. I actually don't know if THC and/or CBD work on their own for pain; I was writing more about using them in combination with SMALLER DOSES of opioids in order to safely make the latter more effective, or to lessen the effects of withdrawal symptoms when one is ready to start weaning off of the opioids.
But it is amazing to me how different people can have such a wide array of individual responses to medications (for example, one antidepressant may work wonders for one person and do nothing--or worse--for someone with slightly different brain chemistry). This is why it seems important that people be allowed to become educated, rather than frightened, by their doctors about various possibilities, and have some freedom to try different approaches/meds until they find the right personal, responsible, treatment plan for pain.
4
This pales in comparison to the long term suffering others describe in these comments, but I have had to have several teeth extracted due to problems caused by poor mouth chemistry.
Anyone who has had a tooth extracted knows the pain is excruciating for several days afterwards. I used to be given a prescription for a few days of Vicodin. I have never abused it. Now I am told, if it hurts try Advil (which does nothing.) So I have several days of extreme pain all because of hysteria and dentists' fear of witch hunting consequences to them if they prescribe needed pain meds.
46
@kat
If you have to have more teeth extracted please find a different dentist or an oral surgeon. You should not be in excruciating pain after a routine extraction.
9
Opioids, psychedelics and the like are drugs with important uses; in the wrong hands (the cruel and the greedy) they become dangerous. It's really tragic; much good would come if more research were done on the positive properties of these drugs.
19
The conquest of pain is one of the great achievements of the human race. To squander that to make political points, fuel drug-oversight bureaucracies, pass draconian laws, intimidate patients and doctors and--yes--keep journalists busy churning out alarmist "crisis" stories is a disservice bordering on sin.
40
@richard Cheverton
The deaths from overdoses here in the US seems well worth "alarmist" reporting and funding governmental oversight including the required testing for patients on longer term opioid prescriptions. We all should be proud to do our part. Opioids have not been banned and are still available when clearly indicated.
3
@Bunbury
Sadly, they are most definitely NOT "still available when clearly indicated." Many MD's are afraid to prescribe them at all, even after extensive surgery. Many patients won't take them at all leading to medical complications from not moving because it hurts too much.
33
@Bunbury
The current epidemic of opioid deaths are caused by fentanyl, whose use is caused entirely by "criminal justice" policies.
I saw a graph in the New England Journal of Medicine. For years, opioid deaths, from heroin and prescription drugs, were about 10,000 a year.
When law enforcement cracked down on prescriptions, people turned to heroin. The prescription deaths went down, but the heroin deaths went up.
When law enforcement cracked down on heroin, prescription deaths went up.
When law enforcement cracked down on heroin and prescription use, illicit drug distributors turned to fentanyl, which is easier to smuggle. Opioid deaths went up to 70,000, and are still climbing.
Drug abuse experts actually call this the "Whac-a-Mole" effect.
The NEJM wrote last month, "In the midst of a devastating public health crisis, large regions of the country are locked in an ideological battle about the morality of harm reduction." https://www.nejm.org/doi/full/10.1056/NEJMp1901276
Doctors have effective methods of reducing the harm from illicit drugs, but politicians and prosecutors are preventing us from using them. Mike Pence, as governor of Indiana, was responsible for a major epidemic of HPV and HIV because of his resistance to needle exchanges and buprenorphone.
Opioid addiction is a medical problem, not a crime. As long as we allow police and prosecutors to overrule doctors, these problems of overuse and underuse will continue -- and get worse.
8
Thank God a voice of sense about pain relief.
47
International comparison please. Why are opioids less abused in other countries? Is it because they are denying opioids to those who genuinely need it (I kinda doubt that)? So what are they doing right that the U.S. is not?
17
It used to be that both American and foreign doctors used opiates sparingly and only in cases like surgery or extreme chronic pain. Sometime in the 1990s there was a push in the US to consider pain management for a wider set of cases. Some of this was good science, but some became corrupted by certain pharmaceutical companies pushing reformulated opioids and downplaying their risk of addiction. Some of the tactics drug companies used to get doctors to prescribe more opioids would have been illegal in some overseas areas, but America also has more of a culture of trying to fix everything (often with pills) that doesn't exist other places.
So it was a mix of poor oversight, corporate greed, changes in medical philosophy, and culture around how people expect to deal with pain and other medical problems.
16
Overacting as usual with trump crowing what he doesn’t have a clue about, as usual. They can’t do anything about street drugs, so blame doctors and pain patients since their unending war on drugs does no good after forty years of it.
3
I took opiates when my hip joint was broken. When I came home from the hospital (3 weeks later), we decided I didn't need them anymore. I had no problem stopping them. If you need them, they probably are not addicting. I really needed them for a time, but not after a time. There was never an issue for me. I expect that is true with most people.
50
Chronic pain from a severe back injury and failed surgery on a consistent basis causes adrenaline and cortisol to pump at high levels. When the pain is unrelenting with pain episodes lasting from a few days to months, it can affect cardiac health and function over a period of many years or decades.
Pain can prevent walking or doing anything but basic maintenance. It can cause one or both legs to drag, electrical shocks down both legs, back, hips, feet at different times. It causes severe spasm and involuntary yelps with a 'wrong' move. You learn to calibrate what you can do every day because the pain level, fatigue and exhaustion from the pain can be overwhelming, debilitating and demoralizing.
When patients with chronic pain require an opiate as a pain management tool for a better quality of life with an already difficult and challenging way to live, it is more than appropriate to do so. If past behavior is a predictor of future behavior especially with regard to prescription drugs, those histories should be taken into account. Some of us with chronic pain more than respect the possibilities and manage those drugs with no problem and with no desire to abuse them.
61
Great except comment. Unrelieved real sustained pain is a gigantic problem to healing in every way. How first do no harm fits into this issue is a great tragic story creating unrelenting pain syndromes and debilities with out relief. It’s inhumane. How doctors who choose not to treat another folly of this misuse of needed pain meds to heal. The rates medical doctors charge for their service insists they educate themselves about the client and the need based use of the drug. It’s without conscious this is the system we are forced into today because of hysteria politically and people suffer unmercifully. You all should look into chronic pain syndrome which happens to untreated pain. Your brain learns it.
7
Finally! This is a very important side to the story that is very rarely talked about. We need to bring this perspective to the conversation more often.
48
@Janet I agree
7
I broke my wrist a couple of years ago and had to have surgery and a metal bar put in to repair some bone crumbling and an uneven break. I took opiods for about 2 and a half weeks afterwards to deal with some quite severe pain, then switched with no difficult to acetimenophen and ibuprofen. I was extremely grateful for the pain relief and experienced no withdrawal symptoms whatsoever. Let doctors prescribe relief for their patients' pain.
71
@Rebecca Hogan Had the same surgery 2 months ago, plate and screws, left after surgery with 6 pills of tylenol with codeine. That's it. Surgeon and OT staff complained when I didn't move it as much as "the bell curve". If I had better pain management, I would have moved it more. Never a discussion about pain and I was afraid to approach it because did not want to be labeled as a "drug seeker" especially since I work in an hospital where I counsel substance abusers. Where is the data that supports INSTANT addicts on a regulated course of pain medications for surgeries or chemotherapy? Doesn't exist. The opioid epidemic and ensuing deaths are real, but swinging from giving out these meds like candy to no one gets them is not the answer. Thanks to Dr. Sekeres for having the courage to have the discussion.
11
Where are the lawyers when you need them?
4
@ElleJ
I assume you mean to force a sane policy on opiate prescription.
Try the Drug Policy Alliance.
2
Opiates should not be restricted to those whose pain is excruciating. I can not use NSAIDs, that extremely useful class of pain meds, and so take a rather low dose of narcotic painkiller for back pain (yes, it works, despite those articles we keep seeing that say otherwise) and sciatica, on a daily basis. The functionality and quality these meds add to my life is hard to overestimate. I have taken this very modest dose for years under my GP's supervision, without increase, and without ill effects if I stop, except, of course, pain. I have taken high does of opioids from time to time for traumatic injuries and surgeries and have always been able to taper off them when the most severe pain has subsided. I do not know why some people are so susceptible to these drugs, but in the rush to cope with the problem of addiction we should not lose sight of the fact that these are extremely useful drugs that can be used without problems by many pain sufferers.
117
@Peter Aretin My story exactly.
25
@Peter Aretin
My story too.
10
Virtually anyone who uses opiates for more than a couple of weeks is likely to experience withdrawal when their pain has become manageable without opiates. The solution to that problem is to taper off. Some can reasonably taper in a few days others may need several weeks but nobody should consider this a sign of weakness. It's just biological diversity and the gene that allows for the worlds fastest taper may turn out to also produce some horrible disease later in life.
Addiction is another matter. There are people who use opioids for a variety of reasons other than anatomical pain. Perhaps some use for "recreational" reasons whatever that may mean. Others will use to suppress the pains of depression or guilt while perhaps not even knowing why they use. I would expect that a large percentage of these folks were raised by parents who also used and had little in the way of emotional talent to pass onto their children.
7
@Bunbury Not at all. I take Tylenol with codeine 4 or 5 days a week, and have for many years. Never any withdrawal.
The problem is that many people, including prescribers, do not realize that difference in potency of different so called narcotics.
Tylenol with codeine is analogous to sipping lite beer, and oxycontin is compared to doing shots of 100 proof vodka.
9
@Mrs H
I'm not sure what "Not at all" refers to but if you were to stop your medication abruptly and no longer use it at all you might find yourself feeling a bit uncomfortable with mild feelings of sweatiness irritability and muscle aches which could persist for a few days to several weeks. Since you return to taking your medication after at most a 2 day hiatus I doubt you would ever experience withdrawal. In any case my contention is that in using opiates in the way you describe withdrawal would hardly be a matter of great concern.
1
@Bunbury I took from two to four hydrocodone pills a day for 15 years, supervised by doctors, etc. When they told me they couldn't prescribe to me anymore because they might lose their license, I had no other options to get more pills. So one day I took my last pill, and that was that. No withdrawal, no nothing. Except that my anxiety came roaring back, and now I'm disabled.
11
This is a great article, and to the point. To get my chronic pain medicines from my doctor, I now have to sign a "contract" with the Federal Government (or some oversight organization) saying they can call me in for a Pill Count at any time. [I have used the same medications, in the same dosage, for almost a decade.] When I spoke to the nurse about these randomized pill-counts, which take two hours out of my day (the doctor's office is miles away and I have no car - it's a long walk from the bus station too), she said, "You signed a Contract." I said I had signed whatever they needed signed to allow My Doctor to give me My Medicine. I said that I trusted my doctor, and felt I had nothing to do with this oversight measure. My count is always correct, and always will be. I'm 72. I have no history of drug abuse. I have a history of sciatica, arthritis, and many shoulder injuries. After 8 years or so, you would think "they" would see that I am not part of the opioid crisis. It is shameful to make things difficult for chronic pain sufferers. One of my friends shattered his arm, and was given only Ibuprofen!
170
@Charlie Messing
I suppose they have to show that they are doing something, even if it is the wrong thing. I, too, have a contract, but haven't been called into to date for a pill count.
11
@Peter Aretin
The Federal and state agencies should be proud of what they are doing to make common sense requirements on us all. If they can save lives by doing this then they deserve our praise. In case you hadn't noticed people are dying.
2
@Bunbury
During the "War on Drugs," the number of opioid deaths went from 10,000 deaths a year to 70,000 a year.
The federal and state agencies are causing those deaths.
Newspaper stories, including the NYT, and medical journals, have described how public health officials tried to set up treatment programs, according to the best scientific evidence -- and federal, state and local agencies rejected them.
The worst thing that the federal and state agencies do is to mandate "drug free" treatment. The scientific evidence is overwhelming that people on "drug free" treatment are more likely to relapse and die.
According to the New England Journal of Medicine, when opioid addicts are switched to methadone or buprenorphine, their death rate goes down, and they're able to function in work and life. If they are arrested, and put in jail, the jails almost always refuse to let them continue with their opioid substitutes. They go cold turkey. Eventually they are released. They often try to "go clean," but almost inevitably relapse. When they relapse, they often miscalculate their dose, overdose, and die. This is the major cause of opioid deaths.
The war on drugs is responsible for those 70,000 deaths a year.
8
OMG! You mean to say that these drugs can (in some cases) actually do what they are supposed to do!? And that the 500,000 deaths are not all in vain?? Good news indeed! Thanks for that, doc.
6
I don’t know about France, but if you take the meds as directed, you don’t die. Street drugs are what’s killing a high percentage of these people.
6
Untreated chronic pain can cause suicide. There's not a lot of research into this, probably because the opioid crisis has distorted the value of proper and controlled use of pain treatment.
Psychology Today has an article that says:
"There are no hard data on how many people with chronic pain die by suicide every year. But there are inferences. The suicide rate among people with chronic pain is known to be roughly twice that for people without chronic pain."
(https://www.psychologytoday.com/ca/blog/nation-in-pain/201511/chronic-pain-and-the-risk-suicide)
When you are in acute pain, you are ill quite apart from whatever is causing the pain. In compassionate societies, ill people are treated, not blamed for their illness.
There is a difference between being dependent and being addicted.
112
@MJM
Re: your last sentence, I do not understand the importance of this distinction. If the alternative is unremitting, excruciating (and soul-destroying) pain, what difference does it make if you become addicted? If opioids were available purely on an as-needed basis--according to the patient's own definition of "needed"--what is the comparative harm?
37
@Wine Country Dude - Addiction is destructive. No ethical doctor will keep writing prescriptions for opioids for a patient in ever-increasing amounts.
That means the addicted person goes to the black market and pays ever-increasing amounts of money which most people don't have. The usual "coping mechanism " for that is resorting to crime to get the money for the drug. That destroys lives in so many ways.
Dependence means working with your doctor to find the dosage of the drug that keeps the pain under control without making you so under the drug's influence that you can't function in society and responsibly hold a job.
Properly managed, the drug takes care of the pain first. If you feel "stoned", it usually means you have taken too much.
The best-practices standard is 80 mg a day. That amount, spread over a day, also means that if you suddenly stop taking it, your body does experience some withdrawal symptoms.
That is the dependence.
The alternative is living constantly with a level of pain that is so soul-destroying that the person realizes they can't continue to live with it,
That leads to suicide,
Thousands of people take opiodes every day. You just don't hear about it because responsible usage is not a social problem.
Thanks for asking.
10
I totally understand. Sorry about your father. See a lawyer.
3
The demonization of opioids by news outlets, including the NYT, is helping no one except the law and order politicians that need a cause to fight in their election campaigns. Nature provides these drugs for a reason, yes I know many are artificial but they are all based on how opium works.
My friend who died f cancer had to fight doctors that were more concerned about running afoul the DEA than they were in treating pain.
The DEA is nothing more than a racist, ineffective organization that now that marijuana is being legalized is chasing other harmless “drugs” to secure their funding.
Abolish the DEA! Legalize everything, it is much less expensive to treat the people that can not control their drug use.
38
@Paulie
Nature did not provide us these drugs for a reason. When certain poppies produce raw opium they could care less whether we are in pain. They are only concerned with producing more poppy plants. We encourage them by selectively planting the seeds from last years crop. Nature is not your mother or I should say that if she is your mother she forgot to take out the addictive stuff from the poppy sap. One giant Oops!
1
This is a story worth presenting to the public. People in severe pain, whether chronic or acute, should neither have to beg for relief nor overcome the fear and shaming induced by those who incessantly talk of addiction. Yes, addiction can be a terrible thing, though managed it may not always be so terrible depending on individual circumstance.
There is an additional, unstated problem here: too little progress has been made over recent decades in developing more effective pain relief methods. In the meantime, however, can we please move on from the silly and destructive stories about how a couple of Tylenol are the equivalent of opiates and synthetics?
90
@A
My Wife, has for many years has endured Chronic Pain, 24 hrs, 365 days, no respite. Was it not for the use of Morphine, her life would be unlivable. How can these Medical Professionals, and or, Politicians, pass judgement on persons who suffer from chronic pain such as this. Offering Pain Counseling and or Therapy will not help in extreme cases, unfortunately, or fortunately, depending on your views, powerful medications are available, and should be so. People do not wish to use these powerful Opiates by choice, it is a necessity and accessibility should not denied. It is a basic "Human Right" to be free from pain, and those who would take that right away, should be ashamed.
38
@A
This article is about cancer pain for which no one has questioned the use of opioids.
Cancer related pain is very different from chronic non-cancer pain and to conflate the two ignores science.
1
@Steve That's not true. Many non-cancer conditions (including certain rare autoimmune diseases) cause the same level of continuous tissue damage that does not heal. Some of these conditions are just as life-limiting as cancer.
4
Prohibition didn't work and neither will laws making drugs illegal. By legalizing drugs, we will put the cartels out of business and save a fortune on enforcement. Generic drugs should be readily available at reasonable prices which will cut the crime rate, help reduce prison overcrowding, and reduce official corruption. If people want to walk around like zombies (as long as they don't drive) or overdose themselves that's really their business. This would also reduce the excruciating pain levels of people that need the drugs and who take them with a physician's guidance. Our restrictive drug laws are a nightmare for those experiencing horrible levels of pain.
42
While I don’t agree nobody realizes that we’ve played right into the cartel’s hands. Make killer heroin, cause a crisis in deaths, government will overreact and prohibit opioids. And way, way more customers. They’re laughing as they launder record profits and people all over America are suffering with horrible pain. Two choices kill yourself or buy from them. Thank you CDC.
3
Maybe so. But my Mom got so viciously addicted to Oxycontin after a fall on the ice that it basically made it impossible to recover, do PT, or get her other meds (she was severely bipolar -- well controlled for 40 years with the right meds, but if they got out of whack, watch out!). She got to where she would deliberately fall out of bed (one time, cracking her pelvis) so she could say she was in pain and beg for more Oxy. That stuff is worse than street drugs. So, she never recovered -- after an 11-month death spiral in the hospital, rehab, and nursing homes, then back to the hospital, rinse, repeat, she died (from a MRSA infection she picked up in the hospital, but that's another story -- and another way the health care system is failing us).
5
That is a heart wrenching ordeal you both went through, so very sorry. But where was the doctor who was treating her bipolar issues? And why didn’t they put her on drug reduction policy in the hospital? Not knowing all the details, I can’t say what, but something, is definitely wrong with the picture you present. I would talk to someone knowledgeable who perhaps can help you. MRSA is horrible, having been on IV antibiotics for months, but it just seems an awful scenario for this to happen. Your poor mother needed help, while I’m sure from the way you’ve described her, she was in pain, worsened by her bipolar state. I’m sure there’s much more but you were very brave to write this.
1
I am allergic to pain killers, NSAIDs and even paracetamol. I have gone into anaphylactic shocks when prescribed normal pain killers. The only thing I have when I am in terrible pain is Tramadol (opiates). I only use it when it is an absolute necessary. It is a relief to know that you have something to help when you crash into the abyss of pain.
27
Dr. Sekeres appears to understand PATIENT CENTERED TREATMENT! Unfortunately too many dentist base treatment on the one shoe fitts all treatment plan. Perhaps it is time for the American Dental Association to revise its position on use of opioids. Please understand that NASIDs can cause strokes, lower sodium etc. etc.
16
How in the world did opiod abuse by recreational users turn into a war on patients in need of pain relief?
I have stage 4 cancer and a year ago my spine fractured in multiple places. My doctors immediately put me on a regimen of methadone and percocet for breakthrough pain. For really severe pain, I even have a little stash of prescribed liquid morphine. I rarely use it, but knowing it is there provides me great emotional support. Overall, my pain care allows me to walk, to have some kind of life.
Do I like these drugs? No. They make me sleepy and have probably contributed to my loss of appetite. I take the minimum possible. But without them, I would choose to die now--get on a plane, fly to Dignitas in Switzerland, and get this over with.
Am I "addicted"? It's hard to know what that word means in the context of my pain and disease. And who could possibly care if I am? I have terminal cancer! Why would anyone want to make my life more difficult by forcing me to renew prescriptions in person every thirty days and all the nonsense that unfortunate patients in some states are forced to endure.
It is an outrage, the ordeal that has been foisted on people suffering in great pain. Opiods are a godsend. Where is the American Medical Association and other physician organizations on this? Doctors, we need your help.
315
@trenton
What "war" are you talking about?
There are no studies demonstrating that opioids are efficacious for chronic pain. I wonder what you would do if your doctors treating your cancer told you they don't care to follow the results of actual research but prefer to treat you based solely on anecdotal evidence.
2
Another misinformed cheerleader. First of all,Steve, they kill the unbearable pain. They’re not supposed to be efficacious for anything else.
21
@Steve
I wonder what you will do if you acquire a condition that brings severe pain. Your analogy makes little sense and your comment is inhumane.
31
I hope some of these well meaning political gurus has a total knee operation. I understand that a small number of people getting an opiate will be hooked, but the vast number will not have a very good day on the first few post op. If the patient does not obtain good range of motion in the first week or so, the results are not usually very good.
41
@James, MD
Agreed...I now spend 2 hours per day, as well as 2 workdays per week arguing with pharmacists and insurance companies trying to obtain appropriate pain medication for my patients. Two weeks ago, an insurance company employee called me and informed me that my patient with a fresh multilevel complicated spinal fusion revision put a gun to his head after the insurance company cut off his opioids. He wanted me to “handle it”. I ask him if he had read my extensive notes sent with the prior auth describing this patient’s high risk for suicide and the current involvement of psychiatry before calling the patient to tell him that his opioids have been cut off. He admitted that he had the notes but had not read them even before denying the patient’s post-operative medication. He said that the patient needed to try NSAIDS before using opioids post-operatively. NSAIDS are contraindicated in spinal fusions for 3 months following surgery. NSAIDS are also contraindicated inpatient’s with bleeding ulcers, which the patient had. Police were involved and the patient was admitted to a psychiatric facility. This patient harm could have been avoided. I called the state department of professional licensing and spoke with an investigator. I will be raising this issue at our state opioid task force meeting.
This is happening every day to patients with total shoulders, total knees, total hips, amputations, spinal fusions and so on. It is torture. This is unethical and immoral.
26
I’ve been going thru the same thing. My psychiatrist told me to go the ER. Is that before or after I kill myself.
5
This discussion would not be necessary if we legalized all painkillers for adults. Why should the government interfere in the right of people to deal with pain even if it leads to addiction? Why would addiction even be a problem if adults could freely get the drugs they become addicted to? Addiction is only a problem if it leads to crime to support the habit or overdose death as a result of taking dangerous street drugs. By acquiescing to government control of painkilling drugs, we are saying the government knows better than we do what our bodies need.
42
Opiate abuse is not about pain control but about escape from other problems. The few rotten apples that doled out huge quantities to abusers ruined it for legitimate pain physicians who managed truly in pain people with legitimate need for relief. The overdose deaths from pleasure seekers is why there is need for oversight but not at the ridiculous levels we see today.
34
@James, MD, your comment illustrates an attitude fostered by our puritanical society and reinforced by our government. Why should the government be telling people how they can and cannot escape from other problems or seek pleasure? If addiction to legalized drugs is not harming society, why should we care what the addict's motive is?
13
What can we do about it, Doc, really?
2
I have a friend, a young woman who rents a room in my house. I’ve known her and her parents for 45 years since she and my daughter played on a softball team when they were 10 years old. She’s intelligent, capable, and her work history is excellent, including management positions.
Ten years ago she woke up with excruciating pain in her back, was hospitalized, and put on medication. She could not be cured but, with the medication, she continued to function well. Then, because of the opioid crisis, her medication was cut in half. She manages but it’s not easy.
She spreads it out over the prescription period experiencing mild to moderate pain daily in order to avoid the unbearable pain at the end of the month. Her pain doctor agrees that she needs more but cannot do anything. She won’t buy it on the street or go to Mexico – that’s illegal. Does she live in pain for the rest of her life? Does she tell a prospective employer: “I’ll be a great employee most of the time except for the 20% when I’m in too much pain.”?
What does she do? Really, tell me. What does she do?
149
@Ron B If her pain doctor agrees she needs more but cannot do anything, find another pain doctor if possible. Maybe reach out to the head of palliative care at a local hospital. And why rule out a trip to Mexico?
15
I wish I knew. Been going thru this myself for a year now. If you know a lawyer, maybe you could talk to him or her. If you don’t, try some of the attorneys that advertise for first consultation free. You may find some relief. There’s also “Pain Network News.com.” There’s many, many people on a blog and the discussion is usually ongoing. Best of luck to your friend and thank you for caring so much for her. That can mean so much. It’s a shame that so many people who are lucky enough not to know about severe pain, think we’re just a bunch of weak, complaining addicts who should get over it. Education is so badly needed.
13
Anxiety intensifies pain. I find that just knowing I have the pain killer at hand eases my anxiety about it and helps me deal with the pain whether I actually take the pill or not. I can deal with the pain much better if I know I have a solution for it if it becomes too much.
83
In the 1970's my father with terminal cancer was being nursed at home by my mother because they had no insurance and he was just months away from Medicare. She learned how to give him Demerol injections but was told to limit the shots. He would be in such pain and cursing her. A terrible time was made even worse.
Imagine the medical community worrying that a terminal patient would become an addict.
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@imlk
That injection is no longer available, no injectors for opioids are available now. Choose death!
1
The need for opiate pain medications is not elective for someone who is in severe pain. But the war on opiates (which merely supplies convenient cover for our nation's falling life expectancy and our pitiful record of infant mortality) has created such guilt feelings on the part of patients that we have become loathe to even describe pain as we really feel it - you are weak willed, or a drug addict even before filling that first prescription. Unless in need, you are unaware that in New York State, your prescription must go from your M.D. to a database in Albany for a approval, then to your pharmacy which then must report to the same database that your prescription was filled and picked up. That you must be seen every thirty days in person by your physician, for the next thirty day supply of MEDICATION - regardless of how difficult and painful that trip to the doctor may be. That you can be forced into the indignity of "dropping a urine" at any time - to provide proof that you are taking your medication and not selling it on street corners or in schoolyards. That should you loose your pain doctor, don't like your pain doctor, find your pain doctor inconvenient, etc. you will be very hard pressed to find another - you will be looked upon as a pill seeker, doctor shopping, or just a junkie. Every "pain patient" could tell a horror story, "pain contracts," unneeded "interventions," and so much more and so much worse, but it would take so many more characters than allowed here.
67
It’s a nightmare. All this has done is lower or end opiate prescriptions for those who need them so they can say the amount of prescriptions is down. It does nothing to help the deaths from all the street drugs that started this whole mess. Something has to happen. Maybe chronic pain sufferers and cancer pain people should get a lobbyist. That seems to be the only thing that gets something done in this government. Money is what gets policy changed.
4
I feel very lucky not to be in pain (but, depending on the day's events, that could change in a heartbeat). My significant other, however, has RA. When she has a flare, she is in perfect misery. And that misery is far less than what some commenters describe.
I do not understand why addiction, even if it were certain in any given case, should obstruct use of opioids. Is addiction to opioids somehow more terrible than unremitting, life-destroying pain?
94
There is a moral, self-righteous, pseudo-Christian attitude that has politicized the whole issue surrounding opiate addiction. Yes, truly there are problems, not the least of which has been the insane marketing techniques of the Sackler family. Doctors and patients have been frightened into fears that addiction will plague every individual, with the best answer being federal regulation that severely limits access to everyone.
Though I've not gone the route of medical marijuana for my chronic pain, I'm glad it is becoming more widespread, for now anyway. And there are multiple alternatives to heavy pain killers -- but for many, yoga, tai chi, and acupuncture are not going to give them a livable life.
We have so stigmatized pain killers that they are almost on a par with prostitution and dog fighting. We have to look more reasonably at individuals and their circumstance, at doctors' responsibility to do what's right for each person, and how as a society we allow meaning to life for every citizen.
83
I’m weaning myself off Tramadol, a relatively mild opiate according to those who prescribed it. I’ve been using it for 4 years to combat moderate arthritis pain in neck. Can’t take NSAIDS. I take no meds for the fibromyalgia I’ve had for the past 35 years. I now understand the meaning of addiction, I spend a lot of time and energy thinking about how to get out of pain.
I appreciate articles like this-pain is real. Our main issue here is how to give a person in pain some hope of feeling better, without pumping them full of opiates.
6
@Bklynbrn. There are many fibromyalgia patients who have used Tramadol to treat their chronic pain for years. If you have been taking it for only the arthritis you are trearing other chronic pain as well. Why are you going off the Tramadol?
10
@Bklynbrn Tramadol was reclassified as a narcotic after decades on the market. A few extremely persistent individuals figured out a way to abuse it, and the recipe was published online. This is also why you have to show ID to buy cold medicine.
Tramadol is in no way the equivalent of a genuine narcotic for pain relief. It is the equivalent of ibuprofen. It is very sad to me that many health care providers do not know this.
9
THANK YOU for writing this Dr. Sekeres. And thanks to the NYT for covering it. I once needed serious pain medication (three decades ago, after a severe burn), and even now I have a couple of friends that wouldn't want to live without them.
I realize there is an epidemic of illegal opioid use that devastates people, and has to be addressed. But one of the worst casualties of the epidemic is the many people that genuinely need strong painkillers, that find it harder and harder to get them, due to the increasing reticence of doctors to prescribe them (and, as the article points out, even the reticence of patients to make use of them due to fears of addiction.)
For those that truly need them, they are genuinely a miracle of modern science. Thing is, we know how to use them safely. Years ago I needed them - 2nd and third degree burns covering an entire arm. The pain was inconceivable. So ... morphine. But even at the time, when pain management science was relatively rudimentary, my doctors slowly weaned me off when it came time. When done correctly, most withdrawal symptoms can be mitigated.
I really think we, as a society, have over-corrected here. Addiction is a tragedy, but it also a tragedy if in our efforts to address addiction, people with a genuine need for opioids start having trouble making use of a seriously legitimate treatment.
115
@JRC I completely agree. We have over-corrected on this problem. I too once needed serious pain control and opioids were the only thing that helped. I think we forget that really bad pain sometimes needs this solution and we shouldn't scare people into refusing these medications. Not everyone gets addicted. For some in appalling pain addiction that could be controlled would be better than the pain. There is no reason these days why people should suffer severe pain.
42
I was diagnosed with a genetic heart condition 3 years ago. I descended quickly into massive heart failure within 3 months. I had a septal myectomy, an open heart surgery so exacting I had to fly to the Cleveland Clinic to have it. I woke up in the cardiac intensive care in such severe pain that I was convinced I was dying. I thought I had not been given pain medication but surely that couldn't be true. I had been given morphine and fentanyl of course, nut felt like an 18 wheeler was lying on my chest. I remained in the hospital a week during which pain medication was administering via a pain pump controlled by a lock and key.
I flew home a week later. The pain was the worst I have ever felt (and I'm a cancer survivor too!) I had to sleep sitting up for 8 weeks and carry a pillow in front of me wherever I went to protect my heart. I had (in effect) been cut in two down the middle to have a piece of my heart removed. Despite all of this, I FOUGHT my doctor regularly about taking pain medication. I was terrified of being addicted. I could barely stand and yet I kept refusing the medicine.
Eventually, I agreed when I was told that I needed to take the pain medicine so I could begin to heal. I still fought occasionally, but I took them for the most part. I was out of work for 4.5 months total and complete recovery took a year!
10
I couple of years a had a terrible accident when I ripped most of my rotator cuff ligaments. I was in excruciating pain day and night. I was literally screaming from pain. Yet no matter how much I begged my doctor for real pain killers, I was refused.
At this point doctors are so scare to prescribe these drugs that we may as well go back to the dark ages. It is very unfortunate that in order for healthy people not to get exposed , those who really needs the pain killers are denied the access as well.
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@Grisha
What are real "pain killers?" If you believe only opioids qualify then you don't know anything about analgesic medications or else you don't believe that patients with conditions like fibromyalgia or diabetic neuropathic pain have real pain as their pain doesn't respond well to opioids but does to non-opioids.
And if no doctors are prescribing opioids please tell me who is writing the tens of millions of prescriptions that continue to get written each year. Are all these forged prescriptions that doctors didn't really write?
1
I was listening to a Fresh Air episode, where a gentleman discussed how he tried to go off opiates after multiple surgeries, but the people who prescribed the drugs refused to be responsible for weaning him off. They even told him to go to a addition clinic (who turned him away saying that their treatment was for those on the verge of losing their jobs and homes, a sort of triage thing).
Don't get me wrong, for chronic health issues that can't be resolved any other way, opioids is awesome. But oh, how this just lack of training taints how they are used.
9
It has been 30-some years since MDs first raised our consciousness about the need for Pain Management and the appropriate use of strong narcotics.
It is disturbing to see that they have to fight this fight all over again in the present day.
62
@Long Time Dem - - You do realize that the story is the raising of the consciousness of the medical establishment around pain management 30 years ago has now been pinned entirely on the nefarious and corrupt marketing of the drug companies. So, human suffering is what - -market driven?
4
@Peter -- It wasn't the drug companies, it was physicians seeing the suffering of cancer patients, like the one described in this article, who spearheaded the pain management movement. "Detail men" had nothing to do with it.
6
@Long Time Dem
Nope, it was the drug companies. Trust me. I was there.
Just as one example, pharma lobbied to make a short course in pain management a requirement for renewing a California medical license. And that course was all about how we under prescribe pain meds, and how addiction is impossible if opiates are used to treat pain.
3
"Abuse." What a weasel word!
On July 4th, we celebrated that this nation was founded on the belief that all have unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.
Pain is the enemy of a satisfactory life, personal liberty and any dream of happiness.
Yet we deny those in pain these rights and assign to gatekeepers - physicians - the power to control their pain.
75
@PayingAttention , the gatekeepers are NOT the doctors, they are the moronic right wing politicians who will work up hysteria where they can. Usually among the poor and hope-deprived people who are most easily lured into drug abuse. Then, they can use the hysteria as a political tool, some sincere rant that blames a political enemy for the addiction.
21
I find it ironic that this article appears directly above the “Aid in Dying” article, because if opioids and muscle relaxers and other pain meds were no longer available for patients with chronic physical pain conditions (myself) or going through harsh medical treatments, it would be extremely difficult to continue living. This is why these drugs were created.
135
@Shari
Except that most chronic pain patients are not expected to die within six months, so they can't take advantage of Aid in Dying.
I wonder if there's a way to measure the suicides of patients who can no longer bear their pain without help?
22
@Jennie
Dr. Thomas Kline (@ThomasKlineMD on Twitter) keeps a running list of chronic pain pains who have committed suicide and specifically cited that it was due to inability to access their medication and thus had no quality of life).
1
This is just heartbreaking, and shows an unquestionable need for relief through narcotics.
But there are many other patients with severe pain who are not such extreme examples. They also need and deserve help, maybe with narcotics. But sometimes things happen - they may overtake medications when the pain is worse, or the meds might get stolen. These are very human situations.
We don't insist that heart patients, or diabetics, follow their medication regimens perfectly. Why do we condemn or even discharge pain patients when they inevitably screw up?
37
My husband has chronic, debilitating pain from spinal stenosis. He is not a candidate for surgery, cannot use any type of NSAID due to gastric issues so his only option is an opioid. He’s closely monitored and sees his neurologist regularly but needs the medication to maintain any quality of life.
Does he abuse them? No. Is he addicted? Possibly. Is it worth it? To him, yes. Without it he would be bedridden and in constant pain. It’s a helluva choice but he has no other options.
197
@Ann As a nurse there are 2 words I usually use when talking about chronic pain. 1 is habituated, that you are used to this narcotic and it allows you to live as good a life as we can make for you and 2: addicted. To me addiction is the use of any drug [tobacco, alcohol, tranquilizers] for purely pleasurable conditions or sensations. People in chronic pain are not addicted. People who sit in their cars and shoot up, or smoke crack or crystal meth are addicts. Pain control allows you to heal, and much faster. I always tell my patients to take their pain pills like clock work for several days, THEN taper or stop. I also tell them to start stool softeners several days before their surgery.
72
@Ann There is a difference between dependence and addiction. Am I addicted to my blood pressure medicine that controls my blood pressure? Am I addicted to my eye glasses that allow me to see better?
62
@Robert
You are addicted if you are aware that your blood pressure medications or glasses significantly interfere with your ability to function and you continue to use them despite being aware of this.
That's the definition of addiction
4
My 79 year old husband suffers from chronic pain 24/7. This has been going on for years as it started with osteoarthritis, then peripheral neuropathy, and about ten years ago RA, followed about five years later with his rheumatologist adding fibromyalgia to the mix. The icing on the cake, so to speak, was added about two years ago with the diagnosis that he has Parkinson’s Disease and he now on memory meds for the Dementia that often accompanies PD. If it wasn’t for his pain doctor and the opioids he prescribes I don’t think my husband could make it through a day. He’s 100% disabled with the VA due to the Agent Orange exposure in Vietnam which is most likely why he has PD and the neuropathy (he is not diabetic). I don’t remember all of the other things that were tried first, such as various steroid injections, that were no help at all. I dispense all of his meds and there is no abuse of the opioids. We both shudder at the thought of his pain doctor not being allowed to prescribe him opioids.
119
I could not agree more that the pendulum has swung too far in the directions of no pain pills for any reason. Had two hip replacements. One in 2017 and one in 2015. The pain before both replacements was unbearable. In 2015 I had no choice but to continue working. Was prescribed pain meds with very careful instructions about use, abuse and tapering off. Because of the medication I could be part of the world, continue to support myself and my family. The pain was still there but It was survivable. Tapered off without any issue. In 2017 the pain management doctor no longer offered any opioids. Offered over the counter meds that were worthless. I spent five months unable to move. No work, no ability to really care for myself. Fortunate to have an amazing husband. What happens to the people who are alone and unable to mobilize at all due to pain? What happens to people who have pain for years, maybe the rest of their lives?
229
@LeslieB Send the doctor a certified return receipt letter telling him that your pain is not being managed. And you are angry that you are suffering needlessly and feel abandoned as his partient. Let him respond. If he then refuses to still treat you adequately sue him for neglect and abandonment. A jury would love to hear what he has done for you. If he is so afraid to prescribe needed drugs to his partients, maybe he should leave medicine. Things have changed nowdays, the doctor MUST chart and document just about everything he does for you. He may make it mandatory to have routine drug testing and make you see a psychologist on a regular basis. This over documentastion prevents the DEA and others from saying he has not followed guidelines when prescribing narcotics. People fire their doctors all the time. We just never really talk about it. But when confronted with the possibility of a suit, efforts will be made. And if the doctor fires you as his patient, in telling others you demanded drugs. Your medical conditioon which is sometimes very apparent will show thew jury that this doctor is just afraid of doing what he was trained to do. But that he has abandonded you as a patient.
27
@LeslieB. We lead l ives of quiet desperation. It's not so quiet all the time however. The pain is so bad sometimes I scream.
32
@PerAxel That's unlikely to be productive. For one thing, doctors get threatened with lawsuits all the time. Pain doctors receive legal and professional threats regularly from patients who want them to prescribe opioids. It's not so easy to scare them into practicing the way that you want. If, as in this case, the doctor continues to offer other treatments, it clearly undercuts the argument of abandonment. Realistically, you are talking about litigating a very common medical judgment (that opioids are unsafe/not justified for a particular patient) and that's just not likely to work.
12
We need more physicians with the courage of Dr. Sekeres to confront those who have swept the pendulum too far in the direction of 'endure the unendurable.'
171
Thank you for this. An earlier article in the Times pointed out that the majority of patients prescribed opioids for pain do not become addicted. This needs to be repeated, and legislators need to be reminded that overreach will deprive many patients relief from suffering.
236
@PL -- in my experience, if one does not taper opiods as pain lessens, they become harder and harder to leave behind.
Oh, and Vitamin C can help with constipation, one serious side-effect of these wonder drugs.
3
@PL
Two things:
1. The only issue isn't addiction. Extended use of opioids can actually lower the pain threshold making the pain worse.
2. It may not be a majority but about 25% of patients prescribed opioids for chronic pain end up abusing them. Considering how many patients are prescribed opioids, that ends up being a lot of people.
3
Please NYT’s, run the excellent editorial you ran about six months ago more often. There are so many agonized people who don’t know what to do.
5
To be deprived of sleep - and in constant pain - is not only nightmarish, but will slow healing. I thank Dr Sekeres for taking the time to guide his patient into accepting that pain relief is something to accept without mistaken fears..
241
How utterly heartbreaking. Thank you for addressing this.
77
Few people who use narcotic pain meds appropriately have issues. If you start doubling doses or using the meds to get high you risk addiction (although these behaviors themselves are misuse not necessarily addiction). People with both acute and ongoing pain have no reason to fear addiction *as long as they use the meds as prescribed*.
I have a birth defect and have had multiple surgeries which has left my spine severely damaged. Everytime I move my spinal cord is being pulled and the bones in my spine are rubbing on the metal holding it together. This is not chronic pain where my brain is creating pain without an injury. This is acute re-injury to my spine every single day. I can feel the bones grinding in my severely deformed feet. I have used opioid painkillers since I was a teenager and they let me have a life. Sometimes the pain is still horrible and nothing really stops it. Sometimes, if I am very careful and limit activities, I can stop the pain meds for a time and be okay. But I will need pain medication on and off for the rest of my life because my body is injuring itself every single day. There is a difference between ongoing pain from a body that does not work and chronic pain where there is no injury or physical process causing the pain and that seems to be a distinction that is missed. I mostly stopped my pain meds for a few years and suffered greatly because when I needed to go back on I was denied for a long time due to opioid hysteria.
148
@JJ
The claim that there is *zero* risk of addiction when opioids are used "as prescribed" is one that opioid manufacturers and others have been rightly criticized for making that fueled the overprescribing side of the pendulum swing - it's just too absolute a statement to be true, even logically.
First, there are probably a few opioid prescribers who aren't very good at what they're doing so following their instructions may not be as protective as you hope.
Second, because of the way opioids trigger in-built reward mechanisms in the brain, any person who ingest them has a possibility of becoming addicted, the likelihood just ranges very widely. There are some people who are at low risk of developing addiction, but none who are immune to it - or at least none who it would be responsible for a doctor to tell they were immune. So, addiction is a a risk, just like an allergic reaction is a risk. But you don't refuse all medications all the time because you could develop an allergy to them (at least most people don't) - you weigh the risks against what good it might do for you.
15
@S
There's a difference between addiction and physical dependence which you don't seem to get. Only a small percent of people will get addicted - meaning not just physical dependency with withdrawal symptoms, but an obsessive drive and desperation to get more. There are ways to manage physical withdrawal, usually tapering, and most people do not develop additictive behavior. If you have problems with other substsances- like alcohol, your risk for addiction not just dependency is high.
4
This article brings tears to my eyes. No one should have to suffer like this when there is medicine available that can help -- it's meant to be used in situations like this.
216
@ET
A lot of patients in this situation are just scared and need to be informed/reassured of exactly that: "This is the situation these medicines are actually made for."
IME, most oncologists know there's a time and place to encourage opioid use, but that puts us out of step with mainstream/general medicine and sometimes with regulations.
15
@S
Most oncologists get little training in pain management. That's why so many of their patients have uncontrolled pain, not because of any concerns about prescribing opioids.
And if you disagree, you show me a single study showing oncologists are well trained in pain management. I don't know of any.
2
I do hope you're teaching a lot of young physicians and students of all types Dr. Sekeres. Thank you.
123
Like this column implies, we are prone to go too far in our condemnation of any opioid use. This arena has become so contentious that the American Pain Society has formally disbanded (that is another complicated discussion).
People with acute injuries and other painful conditions may need opioids. People with severe chronic arthritis may periodically need the drugs, more often if their joint damage is severe and unmanageable by other means.
We should be able to do this, to stop the opioid overuse for every sort of pain without shutting off supply completely. I hope we can do this, but at the moment the addiction problems are so widespread that it can be difficult to see other circumstances.
51
@JSK
I’ve seen a reasonable middle of the road approach lately.
When I got my wisdom teeth out twenty plus years ago the dentist wouldn’t let me leave until my husband returned from the pharmacy and showed them he’d picked up the week’s worth of Vicodin (and prophylactic antibiotics but that’s another column).
Within the past couple of years I’ve had two kids get wisdom teeth out and a friend go for an outpatient surgery. All were handed a prescription slip for three days of Tylenol 3, and told to see how they felt and fill it if they think they needed it.
12
@Di
There are a lot of physicians and dentists who try to be reasonable, but they and others are also nervous due to the horrible behaviors that have been justfiably publicized.
I wish it were as simple as you suggest. It has long been the practice of many prescribers to limit the number of days for acute use, but that does not deal with people with chronic illness, such as the person described in Dr. Sekeres essay (or so many other circumstances).
33
@Di Narcotic prescriptions may not be gfaxed to a pharmacy, they must be tasken in and signed by a person licensed to sign a narcotic prerscription. A doctor or possibly a PA-C. I myself just hadf some surgery and was handed 3 pain prescriptions. 1: for very acute pain for the first 2 days 2: not as strong for the next 5 days and 3: just plain old tylenol. I was told to call the office if my pain was horrible and talk with them about stronger medication and possibly having the need to come into the office again to pick up another prescription. They gave me prescriptions to taper my narcotics. And it worked, like a charm. I was pain free for those first days, then went to the less strong medication which really helped me get back on me feet. Then to tylenol. Now my first and strongest prescription was for 4 mg Dilaudid. A very powerful drug. The second was for Vicodin/hydrocodone 5mg. Doctors need to learn to be flexible in prescribing varying strengths of pain control meds over the course of your healing. And TELL your doctor this is what you want.
6