When I was in residency in the late 1990s, doctors were under fire for undertreating pain. We were reassured that freely prescribing opioids was a low-risk way to treat pain and that less than 1% of patients would become addicted. That assumption was wrong.
In fact, if you Google the phrase “addiction rare in patients treated with narcotics,” you can still find the 1980 New England Journal of Medicine article that we counted on — it has been cited almost 700 times, according to Google Scholar. Only a few people looked at that article closely enough to learn that the researchers only studied patients in short-term hospital stays — not people treated with pain pills every day for years.
We knew doctors were taught that there was no such thing as a dose limit, and that it was safe to push prescription pain medicines to levels previously only seen in hospice care. This makes no sense, of course. Almost all drugs have safe ranges — the dose that is too low to work, and the dose that is so high that it’s dangerous. For example, most people assume that taking 30 Advil pills a day would do harm. Yet we doctors were prescribing the equivalent of 30, 40, or 50 Vicodin tablets a day, and our patients were still in pain. In addition to the pain, though, these patients develop a host of other problems. Their bowels don’t work. Their brains are fuzzy. They can’t remember things. They can’t sleep well. They get depressed and have no energy. Many get sleep apnea. Patients get dependent on the drugs and go into withdrawal if they miss a dose. And more than 30% develop addiction, which leads to lost jobs, lost families, and derailed lives.
The result is that we doctors have actually created disability. People become so impaired they cannot live normal lives without pain pills. Instead of being in pain from an original injury, now people feel pain from the painkillers prescribed by their doctor — either due to mini-withdrawal symptoms between doses all day long, or because of hyperalgesia, the condition where pain pills themselves cause generalized pain. We realize now that long-term use of pain pills changes brain chemistry, sometimes permanently.
With long-term pain pill use, the brain stops producing enough endorphins and dopamine, the chemicals that manage pain and motivation, and lives can’t be normal until those chemicals are replaced or the brain recovers. Fortunately, there are now safe medical treatments that can normalize brain chemistry — some people need them for months or years, sometimes for life. Diabetics have pancreases that stop producing insulin, and we don’t judge people who need insulin shots for life. Recovering painkiller addicts may need the same help.
We in the medical community created this problem; fortunately, momentum is building across the country to try to solve it. Prescription painkillers are good drugs when used judiciously. They soothe suffering at the end of life. They help people get through severe injuries and recover from surgeries. But like many things, a good drug used to excess causes harm.
The CDC’s new website includes powerful six-word stories told by people who have been affected by the epidemic, like the story of these sisters.
There is a way out of this epidemic, but it is not a simple path. First, we need to adopt safe prescribing practices across our health care system — in primary care, the emergency room, specialty practices, and dental offices. Vicodin right now is the most prescribed drug in the country. It is everywhere — in medicine cabinets, in schools, on playgrounds.
Finally, the drug naloxone can be used to prevent death by overdose. Like an EpiPen for beestings, anyone can use it, it requires no medical training, and it has been proven to save lives. Naloxone is also available in nasal spray. Everyone who takes pain pills regularly, or knows someone who does, should have ready access to this drug.
In my 20 years of prescribing pain pills, I have lost patients to drug overdose, and I have seen patients get their lives back. The responsibility I feel for my role in the epidemic fuels my commitment to help turn it around.
Kelly Pfeifer is director of CHCF’s High-Value Care team, which supports policies and care models that align with patient preferences, are proven effective, and are affordable. She leads CHCF’s efforts in maternity care, end-of-life care, and the care of populations with complex behavioral health and medical conditions. Kelly was named the 2017 recipient of the Beverlee A. Myers Award by the California Department of Public Health for her work addressing the opioid epidemic. It is the agency’s highest annual award given to an individual exhibiting outstanding leadership in public health.
Prior to joining CHCF, Kelly served as chief medical officer for the San Francisco Health Plan — a managed Medicaid health plan — and medical director and family physician at Petaluma Health Center. She also served as the medical director for access for Redwood Community Health Coalition, a network of community clinics in four North Bay counties. She continues to practice family medicine. Kelly received a bachelor’s degree in English literature from Oberlin College and a medical doctorate from the Medical College of Pennsylvania. She trained in family medicine at the University of California, San Francisco, program at Sutter Santa Rosa.