Roger Kasendorf, DO, tells the story of a 47-year-old man who shows up for his initial evaluation after being referred by the trauma team. He had been crushed by a tractor, causing amputation of his right leg and causing a fractured pelvis, left femur, and 6 ribs. He presents with severe pain and is in clear painful discomfort. He tells me that he is miserable but doesn’t want to take any stronger pain medications other than Ibuprofen because he doesn’t want to become “an addict”, despite no history of previous addiction or psychological history.
Although I respect this patient’s opinion, it is also important to deal with the problem in front of you. My response to this patient was, “Your UPS delivery man will not be dropping off a trophy because you suffered in pain. The medication is there to be used for a reason.” Addressing the pain aggressively and promptly in a correct manner can prevent problems later on.
Unfortunately, this is not a common perception in pain management. We have so many great treatment options not afforded in many areas worldwide. No longer will someone have to suffer a life-crippling injury when treatment is available to keep them functional and have an improved quality of life.
Physician burnout is at an all-time high while reimbursement continues to tumble down. Many factors have led to this. Let’s tackle them one by one:
Government
CDC
Media
Perception
Recent studies have shown that over 98% of opioid-related deaths are NOT due to a direct prescription from a doctor to a patient. A far overwhelming amount of time, effort, and money is put into prolonged investigation, harassment, and prosecution of well-meaning physicians.
Pressure from state boards and DEA had led to the prosecution of many physicians leading to lost licenses. Although there are indeed cases in which doctors have been unscrupulous in the means by which they too easily hand over dangerous medications, the vast majority have followed strict guidelines.
The CDC created treatment recommendations to address chronic pain in 2016 (which were recently revised this past year to some extent). These guidelines did not address the real issues regarding opioid addiction. Instead, these were focused on strict numerical values of morphine equivalence.
Although I am in agreeance that caution and compliance should be followed when it comes to any controlled substances, the creation of specific number of entities led to many problems. Instead of being treated as “recommmendations”, these were treated as “law”. Both government and private insurance companies immediately found this as a means to not pay for opioid medications and to punish the physicians who prescribe them. This did not take into account the patient’s individual needs or medical history. This also did not take into the fact that many people have been prescribed medications for many years, have been stable on their medications, and have derived great improvement in quality of life from them.
Since the 2006 CDC recommendations were started, suicide rates in chronic pain patients have skyrocketed, and many of those who could no longer receive their treatment from their physicians have had to resort to illicit medications.
The media perception of opioid medications has also led to deleterious results. Reports of celebrity overdoses are immediately reported to have come from the treating physician, immediately dismissing illicit drug use, which is much more than not the real cause of death. Additionally, the opioid medications by themselves may have been appropriate, but the addition of other substances: illicit opioid medications, alcohol, and benzodiazepines, also plays a great factor in this.
Furthermore, the streaming services (HBO, Hulu, Netflix) have each released their own versions of series which show overdoses, relating them to opioid prescriptions. Once again, illicit drug use is not addressed, nor any other factors.
The final barrier is patient perception. Although I never agree that opioids should be an early option in treating pain, they are occasionally necessary for severe conditions. I often come across patients where the pain is intractable. They have zero quality of life, are unable to manage their own activities of daily living, and have a profound effect on their loved ones. However, due to the perception created by the abovementioned means, I will get someone unwilling to receive reasonable treatment.
In summary, opioid medications, although not first-line care, are essential for a percentage of certain conditions that cannot be managed alone with conservative care (physical therapy, acupuncture, etc), non-controlled medications (anti-inflammatories, muscle relaxers), or procedures (steroid injections, surgery). They can be used in a safe and effective manner with proper guidance and monitoring.
