Science Advocacy
Science Advocacy
Over a year ago, I attended a seminar on the current treatments of opioid addiction. The talk was given by a physician at University of Arkansas for Medical Sciences (UAMS) in Little Rock, who has been treating opioid addicts for over 25 years at the methadone clinic. Paradoxically, opioid addiction is treated with other opioids such as naltrexone, methadone, and buprenorphine. The speaker mentioned that throughout his entire career, he has never had a patient who fully recovered from opioid addiction; however, he has had many patients who lead a fulfilling and successful life on methadone.
In 2015, prescription drugs killed more than 33,000 Americans, and half of those deaths involved a prescription opioid,1 and early August of this year, our president of the United States proclaimed that he considered the opioid epidemic a “national crisis.” (Although, as of this writing the opioid epidemic has not been formally declared a national crisis.) So, how did the problem of opioid addiction become an epidemic?
Most opioid addicts that seek help from the clinic are not hooked on “street drugs,” like heroin, but rather, prescription drugs, which may be acquired legally – prescribed by a physician – or illegally – through a friend or dealer. Oxycontin, Codeine, Percocet, or Tramadol are widely prescribed opioids for treating various forms of pain. The danger behind prescribing opioids is that it’s easy to get hooked on them and quickly build up tolerance, and if the patient abruptly stops taking them, they will experience withdrawal symptoms such as anxiety, restlessness, sweating, vomiting, diarrhea, and of course, pain.
In 2017, Mr. Anuj Shah and his research team from UAMS in Little Rock, Arkansas, investigated the likelihood of long-term opioid use following a patient’s first opioid prescription2. For their study, they followed over 1.2 million patients from the date of their first opioid prescription up until the patients were 180 days opioid-free. Mr. Anuj Shah showed that almost half of the patients prescribed a one-month supply of opioids were still using opioids a year later. This study sheds light on the current medical prescribing pattern and paradigm for treating pain. In the past, doctors would prescribe opioids mostly for acute pain that starts suddenly and doesn’t last long, usually after an injury or surgery. Now, the Center of Disease Control and Prevention (CDC) guideline recommends prescribing opioids also for chronic pain such as that due to arthritis, back pain, and migraines3 – hardly rare ailments. So, what are health implications of this study for public health practice? Pharmacists and physicians should be aware that once they give their patients a second prescription of opioids, this doubles the risk of their patients’ opioid use one year later.
Let’s consider another factor in opioid use, one that is more difficult to measure objectively: pain. Nurses, doctors and other health professionals use something called the pain intensity scale. The individual describes their pain on a scale ranging from 0 (no pain) to 10 (worst pain ever). It’s a simple, practical, and fast way to quantitatively measure pain and the dose of prescribed opioids is tailored based on the patients score. But, pain comes in different forms like acute or chronic nerve pain, emotional, social, or even spiritual pain. These forms of pain contribute to the patient’s overall reported score of pain4. In that case, if there are different sources of pain, wouldn’t you try to approach treating pain with multimodal therapies (including more than one therapeutic intervention for pain treatment and management) instead of treating it through prescription drugs alone?
Often, patients who suffer from chronic pain will need increasing doses of opioids to reduce the pain intensity score. Such treatment regimen increases the likelihood of patients become dependent and addicted to opioids. Of course, providing a multimodular approach (counseling, physical therapy, medication, and coping strategies to accept pain) would be difficult in our current pharmacologically-oriented health care system, where basic access to care remains a significant hurdle for millions of Americans. Providing a combination of different therapies not only for pain treatment but management would help patients accept pain. This is something that should be considered in our current health care system.
I asked an M2 UAMS resident anesthesiologist, who prefers to remain anonymous, what is his opinion on the opioid epidemic in the United States. He said: “I believe it’s [the medical system’s] fault. When most patients go into surgery, we prescribe too many opioids to fulfill their expectation and satisfaction. I had a patient come to UAMS because of withdrawal from over-narcotizing after a hip surgery. It’s incredibly sad.” This is a catch-22 for medical professionals who have an altruistic desire to genuinely help their patients, yet are aware of the addictive potential of opioid use: no one wants their patients to suffer, but neither do they want to give them potentially addictive drugs.
Somewhere in the pipeline of drug discovery and development that ends at the patient’s bedside, a few major mistakes have been made. Physicians, pharmacists and patients may not be sufficiently aware of how highly addictive these opioids can be and many may lack accessibility to multimodular approaches for treating pain. A few other big factors that hasn’t been acknowledge in this article are pharmaceutical companies trying to meet the goals of their marketing model and not the needs of the patients. The reasons behind the opioid epidemic are complex, but they are at least in part due to lack of agreement in the field of pain treatment and management in public health practice.
References:
Cool reads:
www.statnews.com/2015/11/30/chronic-pain-intensity-scale/
