When the Prescription Becomes the Problem
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.
US Health and Human Services Secretary Sylvia Burwell recently announced a major federal initiative to combat overdose deaths, and the Centers for Disease Control and Prevention (CDC) just launched a new website on prescription drug overdose, which contains a rich set of resources for patients, providers, concerned family members, and the general public.
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.
Second, we have to improve access to medical treatments that really work for the people who suffer from addiction. Twelve-step meetings work for some, but most people who have been on pain pills for years need treatment to help normalize their brain chemistry and allow the brain to heal as they learn new habits and ways to cope. A booklet of “facts for families and friends” about medication-assisted treatment options for opioid addiction (PDF) by the Substance Abuse and Mental Health Services Administration is available for free on the SAMHSA website.
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.
CHCF has a new emphasis on high-value care, and we are particularly focused on patients who are heavy users of the emergency department and who may misuse prescription painkillers. Our efforts include a collaborative to support residency clinics in safe prescribing, support for expanded use of naloxone, a webinar series on opioid misuse, and an expert convening that explored new solutions to this crisis for the safety net.
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.