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Opioids Under-Prescribed Due to Addiction Fears?

Fear of Addiction Means Chronic Pain Goes Untreated, according to an NPR story that aired last weekend. While there’s definitely truth to the headline, it obscures the nuances of physicians’ reluctance to prescribe opioids (a.k.a narcotics) for chronic pain in general and headache disorders specifically (particularly migraine).

Opioids were originally prescribed for short-term pain, like from surgery or an injury, or for use in end-of-life care. Chronic pain is a serious medical issue that is both under-treated and has limited treatment options, so it’s understandable that opioid painkillers filled that void, especially because opioids are the only source of relief for many people with chronic pain. Unfortunately, they began to be prescribed for long-term use before there were a lot of studies on their long-term effects. Now that research is catching up, this use is being questioned.

Beyond addiction, other potential problems for using opioids for chronic pain include opioid-induced hyperalgesia, tolerance and the systemic effects of long-term use. Opioid-induced hyperalgesia, when opioid use increases a person’s sensitivity to pain, is one concern. Tolerance — which requires taking increasingly higher doses of the medication for it to still be effective — is another. The repercussions of regular (and often increasingly higher) doses of opioids could have on the body’s systems should also be considered.

Headache disorders — and particularly migraine — have additional issues. Rebound headache (medication overuse headache) is the most widely addressed concern. In addition, the American Migraine Prevalence and Prevention study found that using opioids more than eight times a month can cause episodic migraine to transform into chronic. (Diana Lee recently reported that there may be a difference between short-acting opioids and long-acting ones and that long-acting opioids may be OK for long-term pain management for people with chronic migraine.) Headache specialists also believe opioids impair the efficacy of preventive medications.

On top of that, opioids aren’t even particularly effective for any type of head pain. In the video I shared last week, headache specialist Mark Green explained why:

“Part of the reason for that is there are fundamental differences in the chemistry of head pain compared to visceral pain. In the receptors subserving head pain, we really don’t have a lot of opioid receptors, so the upside for the use of opioids is rather low. That’s why we use, for example triptans and ergots. Those serotonin receptors are very well represented on those receptors that subserve headache.”

What do I get from all this?

  • Boiling down concerns about opioid use to a fear of patients becoming addicted is an oversimplification.
  • There are a lot of unknowns about opioid use for chronic pain. As more research is published, the less they seem like a good long-term solution.
  • Head pain is different than bodily pain and migraine may different still.
  • Chronic migraine isn’t a chronic pain disorder, nor are chronic cluster headaches. I don’t know where tension-type headache falls on the continuum, but I’m inclined to believe it’s more on the side of other types of headache disorders.
  • Using opioids can significantly alter treatment for an underlying headache disorder.
  • Mostly, I’m left with a lot of questions (and so are researchers and physicians).

I’m not anti-opioid, but all these unknowns plus the generally negative outlook of what we do know make me very, very cautious. Ideally, your headache specialist would be the prescriber, but fewer and fewer are willing to prescribe opioids (not out of fear of addiction or the DEA, but because of the ramifications for treating the condition you’re using opioids for in the first place). If your headache specialist won’t prescribe them, still be honest with them about how often you use them and at what dose — without that information, your specialist can’t treat your headache disorder properly.

Note: I’ve used words like “potentially” and “can” a lot in this post because not everyone’s the same. It’s important to be aware of the risks, but also to remember that not everyone will have all the same issues.

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Helping Docs Understand DEA’s Assault on Pain Meds

Is the DEA targeting docs who prescribe pain meds to make up for the agency’s past failures? Critics of the agency’s recent crackdown think so, according to a May 19 article in Medical Economics.

“‘If the battles you’re fighting are being lost, then, to win the war, find battles that you can win,’ says David Brushwood, a professor of pharmacy health care administration at the University of Florida, Gainesville, and a critic of government narcotics policy. ‘Doctors are more conspicuous and easier to find than drug dealers, and, besides, they don’t have guns and they don’t shoot back.'”

The six-page article is written for health care professionals, but it is a concise explanation of the problems that doctors face in prescribing pain meds. The recommendations it gives docs to follow when prescribing pain meds can be helpful for patients to understand how to help the doctor function within the system, thus potentially lessening the struggle to get adequate pain relief.

Pain and the Law, a website dedicated to helping health care professionals understand how to work within the law, is linked to from the Medical Economics article and is worth perusing. The site recommends these pain links for patients.

This previous blog post describes a detailed educational document on the DEA’s stance on pain meds.

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“Potheads and Sudafed,” a New York Times Editorial

“Potheads and Sudafed,” a NY Times editorial that ran yesterday, caught the attention (and raised the ire) of About.com’s headache page guide, Teri Robert. The article addresses issues raised by the FDA’s denial of medicinal marjiuana’s efficacy. Columnist John Tierney writes of the conundrum:

Officially, the D.E.A. says it wants patients to get the best medicine. But look at what it’s done to scientists trying to study medical marijuana. They’ve gotten approval for their experiments from the F.D.A., but they can’t get the high-quality marijuana they need because the D.E.A. won’t allow it to be grown. The F.D.A. actually wants to know if the drug works, but the D.E.A. is following the just-say-know-nothing strategy: as long as researchers can’t study marijuana, they can’t come up with evidence that it’s effective.

And as long as there’s no conclusive evidence that medical marijuana works, the D.E.A. and its allies on Capitol Hill can go on blindly fighting it. Representative Mark Souder, the Indiana Republican who’s the most rabid drug warrior in Congress, has been pressuring the F.D.A. to crack down on medical marijuana. Last week the agency finally relented: in return for not having to start busting anyone, it issued a statement stressing the potential dangers and lack of extensive clinical trials establishing medical marijuana’s effectiveness.

For more information about the DEA’s stance, see this post.

FYI: The article is only available on the Times site if you have a paid subscription, but you can probably use your public library card to read it in a full-text newspaper database online. (The database I used is called ProQuest and I accessed it trhough the magazine and newspaper section of the library’s databases. These specific details are only applicable through my library, of course, but I hope they help you navigate your library’s website.)

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DEA’s Stance on Pain Explained

Anyone with pain that requires opioid treatment must read this article on the DEA’s stance on painkillers. In fact, I think everyone who lives in the US should read the article.

Entitled “Treating Doctors as Drug Dealers: The Drug Enforcement Administration’s War on Prescription Painkillers,” this 35-page journal article overflows with illustrative information. Print it out and grab your highlighter. The time investment is well worthwhile.

Here’s the abstract:

Since 2001, the federal government has accelerated its pursuit of physicians it alleges are contributing to an increase of prescription-drug addiction. These highly publicized indictments and prosecutions have frightened many physicians out of the field of pain management, exacerbating an already serious health crisis—the widespread undertreatment of severe chronic pain.

[via Kevin, MD]

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Chronic Pain is Real; Take Us Seriously!

An article in the current New England Journal of Medicine examines how the DEA‘s influence on medical practices for pain control ultimately harm patients. Although the article focuses on end-of-life pain control, the issues affect people with chronic pain as well. The authors assert,

“Uncontrolled pain and other distressing symptoms are the primary concerns and greatest fears of patients facing serious illness. More than 90 percent of the pain associated with severe illness can be relieved if physicians adhere to well-established guidelines and seek help, when necessary, from experts in pain management…. Despite the efficacy of opioids and a commitment by the medical profession to treat pain, abundant evidence suggests that patients’ fears of undertreatment of distressing symptoms are justified. Although a lack of proper training and overblown fears of addiction contribute to such undertreatment, physicians’ fears of regulatory oversight and disciplinary action remain a central stumbling block.”

Again, this is in the context of palliative care, so the practices are a different; the implications are much the same.

Using the NEJM article as a springboard, today’s New York Times addresses the core problem: Currently policy places fear of prescription drug addiction above the lives of people with pain. There’s little regard for those who wonder if a life with excruciating pain is better than no life at all.

The author describes how doctors’ hands are tied to some extent, and that how they work within these restrictions to treat patients or simply turn away from the dilemma all together.

“…[T]he D.E.A. has recently increased raids on doctors’ offices, confiscating files and arresting doctors on charges of overprescribing narcotics to patients who are addicts or drug dealers.

“Most of these physicians are compassionate people trying to help suffering patients but  are sometimes fooled by clever addicts, drug dealers or undercover agents who fake their pain.

“Yes, there are bad apples among members of the medical profession. There are some doctors who charge for medical exams that they never do and provide phony patients with prescriptions for narcotics to feed their habits or sell on the street.

“But should all physicians be subject to intense scrutiny by the D.E.A. and risk arrest and prosecution, leaving legitimate patients to suffer intensely or scramble to find other doctors willing to risk taking them on?

“The growing number of arrests of pain management specialists is exacting high costs for patients, physicians and medical insurers. Some doctors order costly but unnecessary diagnostic tests so they can show the D.E.A. a reason for prescribing strong pain medication.

“Many doctors are simply unwilling to prescribe narcotics, no matter how much a patient suffers. Ignorance, as well as a fear of the D.E.A., plays a role.”

Want to help get this mess sorted? Visit the American Pain Foundation‘s advocacy page for ways you can help. One quick way to contribute is to send a pre-written e-mail to your congressional representatives.

I can’t create a blog-safe link for the Times article. You’ll have to register with the newspaper to read it; even then, the link will expire in about a week.