Pain Management Versus Opioid Abuse: Glimmers of Light

Doc Gumshoe follows up on A Troubling Quandary

By Michael Jorrin, "Doc Gumshoe", October 18, 2017

[ed. note: Michael Jorrin, who I dubbed “Doc Gumshoe” years ago, is a longtime medical writer (not a doctor) who writes for us a couple times a month about health issues and trends.  He does not typically focus on specific investment opportunities, but has agreed to our trading restrictions… as with all of our authors, he chooses his own topics and his words and opinions are his alone]

At the end of the first installment on this subject I promised to lift the curtain on some glimmers of light that have emerged in this troubling picture.   Before getting up to launch velocity, I need to do a bit of review.

First, we need to understand one simple, basic, underlying truth: in most cases, our pain response is an essential survival signal.   The sensation of pain tells us that something is amiss and needs to be remedied.   This is true of both the fast type of pain, which is a response to mechanical or thermal events (bangs, cuts, burns, etc), or the slow type of pain, which is a response to something wrong systemically, whether something relatively trivial like indigestion, or any of a huge and intimidating range of non-trivial conditions and diseases.   Those two general types of pain are transmitted by different nervous systems.   Fast pain impulses get to the brain in less than one tenth of a second after the incident, while slow pain impulses begin to trickle into the brain several seconds after the chemical agents reach the nerve endings, and then increase over longer periods, sometimes as long as hours.

The most immediately useful response to pain is to determine the cause and try to deal with it.   This is generally fairly simple with fast pain.   If you burn yourself picking up the cast-iron skillet without a pot-holder, you can run cold water on your hand and then put on some lotion; systemic pain medication is usually unnecessary.   But if you develop a severe pain in your lower back, and it gets worse overnight and doesn’t go away, you might need to consult a health professional to try to find the cause.   And if, despite the interventions of the health professional and short-term pain medications, the pain persists, you might find yourself in the situation I described in the previous installment.

That situation embodies some inherent conflicts.   As noted in the previous Doc Gumshoe sermon, chronic pain affects close to one third of the US population, and the most effective drug treatments for pain are agents that address the μ opioid receptor, but opioid abuse is endemic here in the USA, and opioid overdoses kill about 175 of us every day.

Lots of different cohorts contribute to this situation in many different ways.   People in pain increase their opioid doses in an attempt to cope with their lives, perhaps unknowingly flirting with addiction, while others knowingly risk addiction in the search for pleasure and a good time.   The economics of the health-care system may make it easier to treat pain with cheap opioids than with some relatively more expensive alternatives that may be less addictive.   And shady characters in quest of easy money provide people with those more addictive drugs.

The pharmaceutical outfits that make and market opioids attempt to dissuade users from becoming addicted to their products mostly through formulation – either by compounding the opioid with one or more other substances that are intended to minimize addiction, or by making slow-release tablets that deny users the immediate rush of pleasure that rewards addicts.   For example, oxycodone, which by itself is an immediate-release agent, is available in seven different formulations intended to deter addiction while perhaps augmenting the basic pain-relieving activity of the opioid itself by adding other analgesics.   In theory, bringing down pain levels by multiple mechanisms would reduce reliance on the opioid channel and thus perhaps lower the odds that the patient would take another opioid pill when the pain level increased.

The formulation strategy is very limited in its effectiveness.   Addicts quickly learn how to crush or dissolve their pain pills and take them in such a way as to get that quick rush that they crave.   And, paradoxically, putting other agents in the mix can add risks.   Both oxycodone and hydrocodone are available in forms compounded with acetaminophen (Tyleno