Pain Meds

If there are 7.4 billion people on earth, and 324 million of them live in the United States, then the U.S. has 4.6% of the world’s population.  Why, then, do we take 80% of the world’s opioids?

Ever since the March 15 publication of CDC Guideline for Prescribing Opioids for Chronic Pain, the internet has been full of responses to those guidelines.  Some in favor, some against.  In general, it seems that those who take (or anticipate taking) pain medicine want easier access to pain meds, while those who aren’t in pain want to reduce the number of drug overdoses by reducing people’s access to prescription narcotics.

Those of us in Washington state have been thinking that the rest of the country doesn’t know how good they have it.  In Washington, doctors don’t have a lot of discretion.  The politicians have dictated how physicians are to practice medicine.  For patients wanting pain medication for chronic pain, consultation with a pain specialist is required by law.  Unfortunately, there aren’t enough pain specialists.  Monthly appointments get expensive – both in paying for the doctor, and in paying for the tests to prove you’re taking the medicine correctly.  Patients have told horror stories.  There’s the MS patient denied pain medicine.  And the patient whose cancer surgery caused nerve pain.

Reducing the number of deaths caused by opioid overdose is a noble goal.  I have dear family friends whose daughter-in-law died from an accidental pain medication overdose.  She had Raynauds and severe joint pain, but no rheumatologist, no arthritis diagnosis or treatment.  That is a tragedy.  Her primary physician prescribed pain medicine to reduce her pain and improve her quality of life.  She was a great wife and a great mom and the pain meds made the difference so that she could function.  One night she took her pain medicine like usual and went to bed.  The next morning she didn’t wake up.  Somehow she’d taken too much.  That single dosing accident means that her kids have no mom and her husband is raising their children alone.  The fact that she was not an addict won’t bring her back.

This is not a small problem.  We’re losing 11,000 people a year to prescription opioid overdoses.  Add to that all the ER visits for prescription overdoses that the person survives (420,000, but it isn’t clear what time period those numbers cover).  A recent study found that when opioids are prescribed for chronic pain, 1/550 people die of an overdose.  On average, this OD takes place 2.6 years from the first prescription.  The numbers get worse, though.  As tolerance builds and doses increase, those numbers climb.  At high doses, the OD death rate is 1/32!

What is the Solution?

I am sympathetic to those who see the death rate due to opioid overdose and want to reverse its upward trend.  When I started this post, I was in favor of the new guidelines.  The more I have learned, however, my position has changed.  Perhaps crusaders have the wrong target.

CauseOfDeath

If we’re going to protect people from themselves, then why not go after the big offenders?  Car crashes kill three times as many people as opioid overdoses.  Alcohol abuse kills nearly seven times as many.  Cigarettes kill nearly half a million people every year.  Where is the outrage?

The fact is that prohibition didn’t work, and I don’t believe the new guidelines will work, either.  Do we want a free nation as envisioned by our forefathers, or do we want the government micromanaging our lives?  At some point, people need to take personal responsibility.

The key is personal responsibility.  As long as doctors can be sued when a patient dies after taking opioids differently than prescribed, doctors will remain reluctant to prescribe opioids for chronic pain patients.  Our current system isn’t working.  Patients who have a legitimate need for pain control can’t get it, but criminals who don’t care about the law have no trouble obtaining narcotics.  Something has to change.

I never thought I’d say this, but maybe the solution is to slap warning labels on the bottles and set opioids on the grocery store shelf next to the wine and whiskey.  Or put the drugs beside the cigarettes.  Chronic pain patients could choose between pain pills and other methods of pain management.  Hospital emergency departments would no longer have to deal with drug seekers.  Pharmacists would lose half their blog fodder.  People would no longer lose their homes due to medical bills incurred in an attempt to obtain pain relief.  I am sure that the death rate would climb, but the fault would rest squarely on the shoulders of the victim, more in line with alcohol and cigarette deaths.

Patients should still consult with physicians to learn about types of pain relief that would be good to try, but the doctor would no longer bear liability.  After that consultation, the patient could stop at the store to pick up the best medication given the situation, cutting out the insurance company.  Pain medicine would cost less and be more available.  Patients would no longer bear the financial expense of monthly doctor’s appointments and lab work.  No more time off work and loss of income due to travelling to/from those appointments.

At some point, we have to admit that the government nanny model doesn’t work.  Give people the tools to make decisions, then set them free.

_________________

See Also:

Scholarships

Last week I received a request to let my readers know about AbbVie’s Rheumatology Scholarship.  To be honest, I’ve struggled with this.  My daughter was already working on the application.  She has a better shot at a scholarship that has few applicants than if there are zillions of applicants.  Do I really want everyone to know about this opportunity?  Since you’re reading this post, you realize that I decided to go ahead and help spread the news.

There are fifteen $15,000 scholarships available to students seeking degrees from either college or trade school.  To be eligible, the student’s doctor must confirm diagnosis of either RA, JIA, PsA, or AS.  More details can be found in the message AbbVie sent:

__________

Did you know students living with a rheumatologic disease like rheumatoid arthritis (RA) or juvenile idiopathic arthritis (JIA) face unique challenges as they pursue their higher education goals? These students have a higher prevalence of short-term school absences when experiencing symptoms. According to one study, over 90% of students with rheumatologic disease seeking treatment at a rheumatology center reported missing school an average of 3.9 days during a two month period compared to the national average of 1.1 days.1

AbbVie recently launched the AbbVie Rheumatology Scholarship, which is designed to provide financial support for exceptional students living with RA, JIA, psoriatic arthritis (PsA) or ankylosing spondylitis (AS), as they pursue their higher education goals. Our hope is that this scholarship will further empower patients to reach their educational goals.

Below is a brief overview of the scholarship for your reference.

AbbVie Rheumatology Scholarship Overview

  • The scholarship is available to students living with RA, JIA, PsA or AS, who are seeking an undergraduate or graduate degree from an accredited United States (U.S.) university/college or trade school, and who plan to enroll for the 2016-2017 school year.
  • Fifteen Rheumatology Scholars will be selected. The award value will be $15,000 for each recipient.
  • Applicants will be judged based on academic excellence, community involvement, written response to an essay question and ability to serve as a positive role model for the rheumatology community.
  • Key dates and deadlines include:
    • Applications are available on RheumScholarship.com.
    • Applications must be submitted by April 4, 2016.
    • Winners will be notified by April 29, 2016.
  • More information on the AbbVie Rheumatology Scholarship, the application process and eligibility criteria can be found at RheumScholarship.com.

 

RA is a Risk Factor for Osteoporosis

Osteoporosis is silent. People’s bones can gradually become weaker and weaker with no outward hints that there is a problem — until suddenly bones break.  Spontaneous compression fractures of the spine can be quite painful and lead to deformity, chronic pain, and premature death.  Broken hips are another risk factor for early death — approximately 20% of people with a broken hip die within one year of the fracture.

In an ideal world, osteoporosis would not occur.  In theory, osteoporosis is entirely preventable.  Since we don’t live in an ideal world, it is crucial that osteoporosis be identified early and treated aggressively.

DEXA is the gold-standard in osteoporosis testing.  DEXA scanners (Dual-Energy X-ray Absorptiometry) (also called DXA) use two separate very low-radiation x-ray beams – about 1/10th the radiation of standard x-rays — to image the hips and spine to measure bone mineral density.  As we would expect from the “dual energy” portion of the name, these two x-ray beams have different energy levels.  Bone mineral density is calculated by measuring the difference between what is absorbed from the first beam and the second.

Test results will provide a variety of numbers.

  • Bone Mineral Density
  • T-Score
  • Z-Score

Bone Mineral Density (BMD) is a raw number indicating the average concentration of minerals in your bones. The higher the number, the higher the bone mineral density and the stronger the bones.  Lower numbers indicate weaker bones.

T-score and Z-score are based on statistics.  Compiling the results from many people has allowed scientists to determine what is normal bone mineral density, and what constitutes strong or weak bones.  Graphing the data forms a picture shaped somewhat like a bell.

A brief aside about statistics:  in statistics, the mean is the average — it tells us what is normal. The standard deviation tells us how far away something is from what is normal. 68% of all data will only deviate slightly from the average (will be within one standard deviation of the mean) — this makes sense because obviously most things should be close to what is normal. On a bell curve (pictured below), the mean does not deviate at all from what is normal, thus the center of the curve deviates zero (labeled 0), and most of the data clusters close to the middle — one standard deviation is labeled +1 (above zero) and -1 (below zero).  95% of the data will be within two standard deviations of the mean (labeled +2 and -2), and 99.7% of the data will be within three standard deviations of the mean. It is very rare for something to deviate significantly from what is normal.

T-score and Z-score numbers indicate standard deviations from the mean on a bell curve.  A T-score compares your BMD with healthy young adults who have good bone mineral density.  A Z-score compares your BMD with others of your age and ethnicity.  Doctors are most concerned with the T-score.

DEXATscores

A bone mineral density scan T-score that is more than one standard deviation below the mean is bad. Between one and 2.4 standard deviations below normal is osteopenia, while a T-score of 2.5 or more standard deviations below the mean is osteoporosis.

Who should get a bone density scan? The general rule is women at age 65 or men at age 70.  Before age 65, the test is only considered if you have risk factors, and if treatment would occur based on test results.  If you wouldn’t be treated, there’s no point in having the test done.  Bone density scans are rarely done on premenopausal women; until menopause, high estrogen levels seem to provide protection against broken bones even in people with low bone mineral density.  The question is, what are the risk factors?

Rheumatoid arthritis is just one of many risk factors for development of osteoporosis.  Other risk factors include:

  • history of taking 5mg or more of corticosteroids for more than three months
  • taking methotrexate (other meds, too)
  • family history of osteoporosis
  • history of an immediate family member with a fragility fracture
  • history of bone fracture as an adult
  • loss of height
  • weight of less than 127 pounds
  • being a smoker
  • menopause
  • eating a diet low in calcium
  • avoiding sunlight (indicative of low vitamin D production)

Given these risk factors, it is no surprise than rheumatologists refer patients for bone density scans.

Everything published about DEXA says that it is painless.  This information is obviously prepared by people who have never had the test.  Although it is technically true that the x-rays themselves do not inflict pain, before the scan is taken you’re strapped to a table in an uncomfortable position and required to stay tied down for the duration of the 15-20 minutes of the test. Although the average person might not be physically injured by the scan, it is inaccurate to say that the test is painless.  More accurately, the test is uncomfortable, but not unbearable.

After the test is complete, the referring doctor will receive a report showing your Bone Mineral Density, your T-score, and your Z-score.  Your report might also include use of the World Health Organization’s Fracture Risk Assessment Tool (FRAX) . This attempts to calculate a person’s probability of fracture within the next ten years with the goal of frightening patients into taking osteoporosis seriously.  A 28% risk of fracture within ten years is about 2.8% per year.  2.8 doesn’t sound nearly as scary as 28%, though, thus the use of ten-year risk estimates.  If you click on the link, select “calculation tool” and then select your continent/country and complete the questionnaire.  The calculation can be made either with or without results of a bone density scan.