By now, if you pay any attention to the news, you have been barraged by reports in the media that the United States is embroiled in an “opioid crisis” or “opioid epidemic.” If you are on pain medications for acute pain (less than 3 months’ duration) or chronic pain (greater than 3 months’ duration), you are in some way involved in the opioid crisis in the U.S. The changing ways that the government, pharmacies, and doctors are dealing with pain control are going to impact your life. This article is meant to help guide you through the story behind the opioid problem and what it means to you.
Before we begin, let’s discuss—what are “opioids”? You’ve probably heard of opium, which is an addictive drug that is derived from opium poppies. Most people don’t consume raw opium anymore, but illegal drugs like heroin, and prescription pain medications like morphine, are made from opium. Heroin and morphine are called “opiates”, because they are natural derivatives of opium. “Opioids” are synthetic relatives of the “opiates.” “Opioids” are the prescription pain medications you have heard about, including meds like codeine, hydrocodone, oxycodone, Fentanyl (the drug that killed the pop star Prince), and others. Some opioid brand names that you often hear are Vicodin, Lortab, Percocet, and Oxycontin.
Opioids are very useful in the management of pain in acute (short-term) situations. For instance, wounded soldiers on the battlefield get morphine. Patients undergoing surgery often get Fentanyl or related drugs in the Fentanyl family. In my orthopedic surgical practice, opioids are frequently prescribed in two situations: acute post-operative pain following surgery, and pain from broken bones after an injury.
There is not much controversy about using opioids for acute, severe pain. That’s what opioids are for. There is controversy, however, in continuing the opioids after the first week or two, because it is now known that short-term pain medication usage can lead to physical dependence on pain meds, which leads some patients to not want to get off the pain meds when they should. So, the current recommendation is to have an “exit strategy” from pain meds right from the moment they are first prescribed. If opioids are started for acute pain, doctors are encouraged to make sure that patients know they are only meant to be continued for a short time, and patients and doctors should work together to make sure that acute (short-term) opioid use does not turn into chronic (long-term) opioid use.
The bigger controversy, however, is the use of opioids for chronic pain (meaning pain lasting greater than 3 months). There is poor evidence in the medical research that opioids for chronic pain are all that effective. This was not well-known in prior decades, which is one of the reasons why opioids for chronic pain got so prevalent in the United States. But now that the problems and dangers related to opioid use for chronic pain are known, there has been a huge policy shift in the U.S. (by the government, pharmacies, and doctors) away from the use of opioids for chronic pain. Unfortunately, there are now large numbers of people who have developed physical dependence on opioids, so getting all those people off opioids is a daunting task.
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Interestingly, this problem is unique to the United States. The rest of the world never adopted the use of opioids for chronic pain. The over-reliance on opioids in the U.S. has come to be known as “the failed U.S. opioid experiment.” There have been studies done about whether people in the rest of the world are in more pain than all the well-medicated Americans, and it appears that they are not. In fact, Americans paradoxically seem to be in more pain. This suggests that opioids are actually causing the pain. This might seem at first like a real contradiction, but. . . hold that thought. There is more information below on why that has happened.
The first two points to remember from this articles are:
#1) The medical research is poor that opioids are effective treatment of chronic (greater than 3 months) non-cancer pain.
#2) The rest of the world does not use opioids for chronic non-cancer pain.
So how did doctors in the U.S. let millions of Americans get used to opioid pain medications for chronic pain? That is a difficult question without a single best answer, but here are some of the reasons:
- Back in the early 1990’s there was a bunch of research done about how many hospitalized patients were not getting adequate pain control. Speakers went on the lecture circuit promoting several principals that turned out to be essentially wrong. These speakers lectured that pain should be a 5th vital sign (after temperature, pulse, blood pressure, and respiratory rate). These speakers promoted the idea that everybody’s pain should be able to be reduced to a 3 or less on a scale of 10. Finally, these speakers taught that if patients are truly in pain, they will not become addicted to pain meds. BUT: We now know that chronic pain patients have to be evaluated in a more complex manner than just a 1 to 10 scale, and that patients in chronic pain rarely report a pain scale of 3 or below even if you give them so much medicine that you almost kill them, and that patients in pain will definitely develop a physical dependence on pain meds, some of them even becoming addicted.
- Doctors widely mis-interpreted the medical research on cancer pain and end-of-life care and applied the research to chronic non-cancer pain, as if cancer and non-cancer pain were the same thing. BUT: We now know that cancer pain and chronic non-cancer pain are two entirely different things, so doctors were essentially ordering opioids for chronic pain without any research to back them up.
- Government entities started grading doctors and hospitals on how well they control pain with an inappropriate emphasis on “pain as the 5th vital sign.” UNFORTUNATELY, this led doctors to write for lots of pain meds to make their numbers look good.
- Pharmaceutical companies got entrepreneurial about marketing new and better pain meds and, in the process, they actually created a demand (and a black market) for drugs like Oxycontin.
- Doctors started to get employed with contracts calling for “productivity,” which essentially means more patients seen per hour. Since it takes 2 minutes to write an opioid script but about 40 minutes to counsel patients about other treatments, doctors wrote a lot of opioid scripts.
- American medicine has been overly occupied with procedures and medications. Americans have been led to believe that modern medicine can “cure” everything. Along the way, the concept got lost that most chronic pain cannot be cured, and that frequently the appropriate treatment is to teach patients to stop catastrophizing about chronic pain and learn to cope with it. This is often a difficult message for Americans to accept, because they can’t understand why we have fax machines, smartphones, and microcomputers, but there are still diseases that cannot be cured.
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The number of opioid scripts in the U.S. tripled between 1991 and 2011, and then it became apparent that the death rate due to opioids was out of control. In 2016, it is believed that over 50,000 people died of opioid-related complications (about half from prescription opioids and half from illegal drugs.) Opioid overdoses now kill more people than car crashes. Many of these people were taking only 20-50 morphine equivalent milligrams of opioids daily. To put that in perspective, 20 morphine equivalent milligrams of daily opioid is the same as only four 5-milligram Vicodin or Lortab tablets daily, a very common dose. Most of these patients who died just stopped breathing. And the problem is compounded by the fact that a lot of patients are on benzodiazepines (medicines like Xanax and Valium that are commonly prescribed for anxiety disorders). The combination of opioids and benzodiazepines is especially lethal. Patients on multiple meds are more likely to just stop breathing.
Opioids present a set of unique problems for our orthopedic patients. Let me list a few of them here:
- Opioids make surgery not work. Patients who are taking opioids pre-operatively for their chronic pain problem get worse results from total knee replacements and from spine operations. It is also more dangerous to operate on these patients, because they are so used to the opioids that it takes excessive (and dangerous) doses to control their immediate post-operative pain.
- Opioids cause pain. Your body naturally makes chemicals called endorphins. Endorphins are the natural pain-fighters that allow you to deal with the daily aches and pains and minor injuries of life. When your body is given opioid medications, your body shuts down its own pain fighters—it doesn’t make the endorphins. So opioid-consuming patients have a hard time coping with the day to day insults of life like scratches, cuts, sprains, and strains. People on chronic opioids have a lot more pain flares than people who don’t take opioids, because people on chronic opioids are not making their own endorphins.
- Opioids cause tolerance. Tolerance is when the same dose of a drug doesn’t work anymore because your body is “used to it.” Tolerance is a big problem, because as you need higher and higher doses of opioids to achieve the same effect, your chances of complications (like stopping breathing and dying) go way up. In chronic pain of greater than 3 months, most patients are taking opioids just to feed their tolerance and no longer for the original pain problem.
- Opioids cause physical dependence. This happens to everyone who is on opioids for more than a short period of time. Physical dependence means that you will have unpleasant symptoms, such as sweating or abdominal cramps, if you try to stop the medication “cold turkey.” In this practice, we usually recommend tapering opioids 10-25% at a time. We believe that cutting the dose by 75% all at once will likely precipitate withdrawal symptoms.
- Opioids cause a wide variety of side effects including constipation and nausea/vomiting. In the U.S., a large industry has grown up around marketing treatments for opioid-induced constipation and opioid-induced nausea & vomiting, when instead the emphasis should have been on getting chronic pain patients off opioids.
- Finally, opioids can cause “opioid use disorder” or “addiction” in some patients. Most patients on opioids for chronic pain do not get addicted. However, there are some patients who exhibit “aberrant behaviors,” such as secretly obtaining opioids from multiple doctors or pharmacies, or insisting on getting opioids even after they have had a life-threatening complication from the medication.
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There are also additional problems related to over-prescribing of opioids. Lots of partially used opioid scripts are sitting in medicine cabinets across the land, and many of these drugs have fallen into the wrong hands. Teenage experimentation is one of the problems. Drug diversion is another problem (people selling drugs on the black market for profit.) Keep in mind that most Percocet or Oxycontin tablets on the street were diverted from somebody’s originally legitimate prescription.
The Centers for Disease Control (CDC) has recently published a guideline for doctors on opioid use in chronic pain. This government agency emphasizes that opioids should never be the first choice of medication for chronic pain. The government recommends that first-time pain med scripts be no more than 3 to 7 days in duration. Starting in February, 2018, CVS Pharmacies nationwide are going to be enforcing a 7-day limit on new prescriptions for opioids. Express Scripts has also announced dosing limitations. The media in Kansas City (particularly the Kansas City Star) have recently started attacking and defaming doctors that they believe are inappropriately prescribing opioids. I personally think that the KC Star stories in this area are not very good, and that the reporter doing the stories needs a little education on the topic—but the fact remains that the government, the pharmacies, and the media are all intervening in the opioid issue. The decision whether and how to prescribe opioids is no longer just between the patient and his/her doctor. There is a major movement in society away from opioids for chronic pain, and all patients need to be aware of that and willing to participate.
In the orthopedic practice here at Ransom Memorial Hospital, the vast majority of our opioid scripts are for patients who were already on opioids before they came under our care. We have worked to make their pain medication regimen somewhat more reasonable than what they came to us on, and also to encourage non-opioid treatments and tapering off opioids.
Every patient in this practice who is on chronic opioids has their pain medication regimen reviewed to see if they can minimize, taper, or discontinue opioids. Of course, we are still primarily interested in helping people in pain, as 98% of patients who come to an orthopedic practice are coming for pain (with only a few coming for non-painful conditions like deformity or numbness or instability of a joint). We start by making sure that every patient’s work-up is complete. In other words, have the appropriate tests been done to find what is causing the pain? Have all the appropriate treatments been ordered, such as physical therapy, surgery, non-opioid medications, topical pain creams, injections, Pain Clinic referral, pain management group at the mental health facility, etc.? After this evaluation, we find that some patients do not require an orthopedic surgeon, and those select patients are being sent back to their primary care physician or a Pain Clinic specialist for further discussion about their medications. We keep other patients in the orthopedic clinic, usually because we were the ones who started the opioids, or because we are contemplating doing an operation, or because they are still being treated for pain within the first few weeks or months after an operation that we performed.
What keeps us going is that we can often help pain with a joint replacement or successfully fixing a broken bone or removing a herniated spinal disc. But unfortunately, chronic pain is often a challenge that cannot be completely solved. Many patients get incomplete relief from orthopedic care and are left with working on coping mechanisms for their pain. What the “failed U.S. opioid experiment” and subsequent “opioid crisis” have taught us is that, for many patients, the answer is not in a pill.