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.


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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Perturbed, frustrated, aggravated, irritated, upset, disturbed, annoyed, bothered, discouraged, disheartened, dispirited, downcast, dejected…  I need a bigger thesaurus.

When I left rheumy #1 for rheumy #2, I was clear about what I wanted:

  • a doctor with whom I had good rapport
  • a doctor in private practice, not owned by a hospital
  • a doctor who saw patients without shuffling them aside to a PA

For a few years things were going well.  Unfortunately, about a year ago my doctor’s practice sold out.

Once they were owned by a hospital, things changed.  First thing to go was the excellent front office staff.  They were moved elsewhere within the system and replaced by lemon-suckers who just seem to be going through the motions.  Next my doctor’s MA (who always managed to process prescription refills within one day) disappeared; it now takes five days to approve refills and there’s a different MA every time I’m there.

To add insult to injury, the hospital brought in PAs.  Instead of seeing my private MD, I now see a hospital-employed PA.  The PA might be a nice person, might be competent after learning to do joint exams without causing pain, might be a lot of things. What the PA is not is the doctor with whom I established a relationship.  I feel betrayed.

Now the office is calling to move my appointment.  It seems that the hospital system has decided to open another clinic at another one of their hospitals.  My choice is to drive an extra 30 minutes or move my appointment to a different day.

I want out, but there doesn’t seem to be any point in finding a new doctor right now, since whoever I find could eventually sell out, leaving me right back in the same position.  Instead, I will show up for appointments as rarely as possible so that my prescription refills will be approved.  My youngest child is twelve; in six years he’ll head to college, and four years after that he should graduate.  That means I just have to deal with this ten more years before we can retire and move away.  If I can get away with follow-up visits every six months, that means I only have to go in twenty more times.  By then, I expect the medical profession to have undergone significant changes, and finding a new rheumy will likely be a completely different situation than it is now.

Twenty might sound like a lot, but I remember how many appointments I had the first few years after I was diagnosed. Twenty is nothing.  Although I was unhappy about things when I started this post, I actually feel better now.  I can endure twenty visits.

Early, Aggressive Treatment

Early, aggressive treatment is the standard of care for rheumatoid arthritis.  Thirty years ago, the standard was to use NSAIDs, only adding methotrexate or another DMARD after permanent damage had occurred.

We now realize that DMARDS modify the course of the disease.  They slow down progression.  They are supposed to be used as soon as possible so that the least amount of deformity takes place.

Why, then, are children still treated with NSAIDS?  I am fuming!  It took years for my daughter to even get a diagnosis.  When someone finally put a name to her joint pain, NSAIDs and exercise were prescribed.

Initially, that helped.  It wasn’t great, but when things are really bad, any improvement is nice.  For quite some time, though, it hasn’t been enough.  Last summer I expressed concern that my daughter was missing too many activities due to uncontrolled joint pain.  Her rheumatologist listened and blew me off, suggesting that she just needs to exercise more.

News flash:  at some point, the pain has to be controlled to make more vigorous exercises possible.

If one shoulder hurts, the doctor will do an exam, maybe order x-rays, diagnose tendonitis, and give a cortisone shot before sending you to physical therapy.  If one hip hurts, the doctor will do an exam, maybe order imaging, give a cortisone injection, and write a referral to physical therapy.  Same thing if it’s an elbow or a knee.  BUT for some reason, when my daughter has tendonitis and/or bursitis in multiple joints, she does not get expensive imaging (yay) or steroids or PT or a different med (😦 ).  She’s told to exercise and stick with ineffective NSAIDs.  They’ll treat tendonitis in a single joint, but when the problem is due to her immune system gone postal, she’s SOL.

This is affecting her schoolwork and her social life.  Do I give her an F in typing if she is in too much pain to be able to sit at a keyboard and position her shoulders/elbows properly so that she can complete her typing assignments?  Do I give her an F in science when her knees, hips, and back hurt too much for her to stand and perform experiments?  Does she just never do things with friends because she is in too much pain to get out of her chair?

This has gone on too long and is getting progressively worse.  Last weekend she was in tear because the pain, even after adding acetaminophen to her NSAID, was intolerable.

Yesterday I finally phoned the rheumatology nurse line and asked if there’s anything we can do to step up her treatment plan, or – at the least – do something temporary to relieve her pain so that she can get back to her exercises.

The nurse finally called back.  My daughter now has a referral to a pain clinic.  Are you kidding me??!!!  A pain clinic?!!!  She does not need counseling or pain medicine.  She already has an exercise plan – she’s in too much pain to do it.

Everything I’ve read says that the prognosis of enthesitis related arthritis is related to age of onset.  Maybe the prognosis would be better if the disease was treated more aggressively!  NSAIDs do not qualify as aggressive treatment.

Sulfasalazine is supposed to be very effective in treating the spondyloarthropathies.  Methotrexate is pretty scary to think about giving my sixteen year old, but it would be better than having her unable to function.  Even a quick steroid taper has potential.

I recognize that I have not been to medical school.  There are many factors that I might not be aware of or understand.  However, it would not be that difficult for the doctor to explain the indications for stepping up treatment.  If my daughter will be unable to function then she should quit dreaming of earning her DPT.

For the life of me, I do not understand why my daughter’s rheumatologist won’t try something else.