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.

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See Also:

Quantifying Pain

Wren has a post up, aptly titled Pain Scale Purgatory, responding to RA Warrior’s blog carnival (for which neither of us wrote a post).

Nobody likes having to guess what the 1-10 pain scale means.  What it means to one person isn’t necessarily what it means to anyone else, and people rarely ask for your frame of reference.  What if, since we’re already carrying around our meds list (you are  carrying your meds list, aren’t you?), we also carry around our own pain scale?  Here is my contribution:

painscalecolors

  • 1-2 is tolerable
  • 3-4 I’ll think about taking a tylenol
  • 5-6 I’ll definitely take a tylenol, and maybe some ibuprofen, too
  • 7-8 there is definitely something wrong and I’m finding someone to drive me to the doctor
  • 9-10 someone is dialing 911

Wishing you many days of only mild pain.

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The original faces pain scale was developed by Donna Wong and Connie Baker to help children communicate their pain level.  I have seen multiple variations throughout the internet and hadn’t realized that the Wong-Baker FACES Pain Rating Scale has a copyright.  I’ve completely redrawn mine, and hope it’s not considered a copyright infringement.

Ambiguity

One thing I like about taking my daughter to Children’s is that at the end of the appointment we’re handed a piece of paper summarizing what we’ve been told.

It’s a bit frustrating, though, to look back at the paper to discover that what seemed to make perfect sense at the time, now isn’t quite as clear.  Three weeks ago, “Call if the pain gets worse,” seemed pretty straightforward.  Now it’s not.

Worse than what?

  • Worse than it was at that appointment?
  • Worse than before starting a daily rx NSAID?
  • Worse than it was before starting PT?
  • Worse than usual but not as bad as it sometimes gets?
  • Always worse, or sometimes worse?

This is so *$%& frustrating!

This morning my daughter took her usual NSAID, then added 1000mg of acetaminophen and tossed a couple rice bags in the microwave so she could put some heat on her hips.  The pain is bad enough that she cancelled her horseback riding lesson.

I don’t know if this qualifies as being worth a phone call to the doctor.  The pain is definitely worse than it was at her last appointment.  She’s back to where she was before starting the NSAID – but she’s not vomiting from the pain.

To call or not to call.  That is the question.

For now, I’m going to wait.  I have a prescription for a different NSAID, so we’ll see if switching makes a difference.  I doubt it, but we’ll try the obvious things, first.  She’ll resume the PT exercises that she’d been told she could discontinue; maybe that will help.  Heat definitely lessens the pain.

And next time I’ll try to view those instructions through my crystal ball.