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    The opioid pain paradox

     

    He was calm and relaxed, and could think clearly. But after several hours as the drug wore off, symptoms crept back, he re-traced the outline of his descent and by the next morning, he was again completely severed from reality. He could remember his period of lucidity but could not return to it. He was admitted to a psychiatric ward for about two weeks. He emerged moderately improved, and I told him what I had actually done.

    What has stayed with me is the realization that mental pain and physical pain have the same neurochemical representation in the brain, at least for opioids, for some people. One can see how this might complicate pain management.

     

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    It is well-known that depression often co-exists with chronic pain, and can even precede it. It is equally well-known that opioid abuse accompanies many psychiatric disorders. In a June 2016 New York Times editorial (“Can opioids treat depression?”), psychiatrist Anna Fels posits that opioids may be able to treat resistant depression as well as borderline personality disorder. We believe we can differentiate “legitimate” patients seeking relief from their pain from “drug-seeking” ones trying to relieve their anguish. Sometimes, the dividing line is nonexistent and confounded by the fact that it is illegal to treat mental illness with opioids.

    Our willingness to use opioids to treat chronic noncancerous pain is only a few decades old. It has been a godsend for many patients, a gateway to addiction for some, and a problem for doctors trying to do the right thing. Guidelines are vague and often not evidence-based, and law enforcement, in its desperate attempts to stanch the overuse epidemic, has sometimes prosecuted physicians inappropriately.

    Our society is awash with drugs, prescription and otherwise. Marijuana exploded into the middle class in 1966; cocaine did the same in the early ’70s. This did not involve physicians (nor did nicotine and alcohol). Doctors did accelerate their opioid prescribing during the 1990s when pain became the “fifth vital sign.”

     

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    But attempts to stem the epidemic with tighter regulations have been unsuccessful, and heroin and fentanyl are replacing oxycodone as street drugs. New York State initiated mandatory e-prescribing, in effect since March 2016, and there has been a 6.7% dip in the number of opioid prescriptions (per New York State Health Department). But, there are still record numbers of fatal overdoses (a 60% increase in New York City in 2016, according to the Wall Street Journal), the majority of heroin and fentanyl. New York physicians are sent a printout of all controlled substances we’ve prescribed each month, to remind us we’re being monitored.

    Next: Free of pain is new 'Holy Grail' of our culture

    Robert Bobrow, MD
    Dr. Bobrow is a Clinical Associate Professor of Famiy Medicine at Stony Brook University, Stony Brook, NY. He directs an Opioid Overdose ...

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    • Anonymous
      Some of us have been in medicine long enough to remember when Darvon and Darvocet, Fiuricet, Fiurinal, and numbers of other non-opioid and non-addicting medications were commonly used effectively to treat pain. Interestingly, all those alternatives to opioids were removed by the FDA just as the pharmaceutical companies all announced "bigger and better" oral formulations of opioids to be released. This all occurred simultaneously to each state's medical boards suddenly dictating physicians to be ultra-conscious and responsive to "PAIN" symptoms from patients. On hindsight, obviously none of this was an accident and none of it occurred in a vacuum. The fact that the FDA cooperated by removing the competitors to those new oral opioid meds remains very disturbing. Now that there is new litigation in the works, regarding the pharmaceutical aspect of our current opioid epidemic, perhaps people will begin to really delve into how this situation evolved in our country.
    • [email protected]
      Bob, I cannot offer you professional feedback, as I am not a medical professional. But as an engineer and a patient on the recovering end of a very long and painful journey, it is my opinion there is no simple solution to this dilemma. We would term it as a higher order, or multi-dimensional, or whatever works. But maybe I can offer you my perspective. I was injured in my last combat tour. A simple, almost embarrassing grade 2 or 3 tear of multiple muscle groups in my calf (Soleus, Gastroc, and plantarus). As a leader, I had to endure the pain to see the deployment through. Sadly, it went downhill from there. The scar tissue and fascia required a four-compartment fasciotomy, and eventually it plugged the popliteal opening and began killing the nerve. Every step was like an ice pick sticking into the center of the calf. Finding a doctor willing to treat the pain in a sequential, planned, and caring manner seemed to be the hardest challenge of all. Since these are not just sympathetic nerves, blocks would just waste the muscle. I was literally begging orthos to help find a way to end the hell I was in. Even the chainsaw in my garage was tempting one day. FINALLY, a pain specialist took a risk to treat the pain with carefully dosed NORCO and targeted bupivocaine blocks to identify the location of the deinnervation and we got it released. By that time, CRPS symptoms had begun, and we had to work fast. The popliteal opening had almost completely closed and scar tissue was adhering to the tibial nerve all the way to the sympathetic branches. The only thing that kept me from putting a bullet in my brain was a caring doctor willing to treat the pain with multiple approaches, a plan, and yes, a simple narcotic. That NORCO was a significant contributor to saving my sanity, and possibly my life. I wasn't depressed because of an imbalance. I was enduring nerve pain 24/7 I wouldn't wish on anyone. Through this adventure I met several of the most uncaring, mistrusting, and acutely accusing medical professionals I never thought existed. Even when faced with an OBVIOUS, well-documented need, the fear of treating patients with pain has taken an almost medieval level of fear. Fear of being raided by state police. Fear of being charged with murder if a patient overdoses. It doesn't have to be this way. Now that we're done, I actually have what feels like a criminal record. After begin gutted like a fish last year for a burst appendix, I was given FIVE norco. FIVE! Why? Because they saw I had a history of being a pain patient in the mandated narcotic tracking system. No one asked about the history. Not one discussion of pain. If I had access to heroin that week, there would have been no question I would have used whatever I could get my hands on. I wonder how many give in to suicide. I can assure you this fear is harming patients because I lived it. There was a time doctors took an active role in managing pain. You protected patients from the alternatives by giving them MANAGED care. Now you send them home with Ibuprofen and if they are lucky, they are told to suck it up. And we wonder why there has been a surge of narcotic addiction, especially in blue-collar working states. If you want to quell the crisis, you must work to return to taking care of patients. Had I known then what I know now, I might have traveled to France to have my leg removed below the knee. Because the only other option was a needle from the street. This needs to be fixed.

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