[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]
Here are three statements about the overall situation, which I hope are clear and accurate, and which essentially point in opposite directions:
One: Chronic pain affects more than one hundred million Americans – more than diabetes, heart disease, and cancer combined. This is according to the National Institute of Neurological Disorders and Stroke.
Two: The most effective treatments for pain are drugs that address the μ opioid receptor.
Three: Almost one hundred million Americans used or misused prescription analgesics containing opioids, and opioid abuse killed about one hundred and seventy five of us every day in 2016.
If you are reading this in the hopes that Doc Gumshoe has any answers to this quandary – and it is a quandary, I hope you’ll agree – I’m sorry to disappoint you. But perhaps I can point to some glimmers of light.
To start with, let’s look at the groups of players in the mix, each with its own goals and concerns:
- Patients who are experiencing pain want relief for their pain symptoms, to state the obvious, but they have at least heard about the perils of opioid addiction and certainly do not want to go down that path.
- Doctors who treat these patients also want to provide pain relief for their patients, but they definitely do not want to be identified and branded as over-prescribers of opioids and thereby contributors to opioid addiction.
- Health insurers often put themselves in the position of knowing better than everybody and sit in judgment as to what works and what doesn’t, with regard both to pain relief and also to minimizing addiction – but their eye is generally on the bottom line.
- The authorities – police and elected officials – pay much more attention to the problems of addiction, which they have to contend with, than with the problems of people undergoing pain, which is not their affair.
- The media focus on the new part of that quandary – pain has been around since the dawn of time, but opioid addiction is hot news.
- And the public at large mostly goes with the media.
I left out one group – people who take opioids not for pain relief, but for their own pleasure or satisfaction of some kind. I try to make a distinction between this group, on the one hand, and individuals who started out using opioids for pain relief, found it difficult to reduce the dose (“wean off”), and ultimately became addicted. My focus in this piece will be on the second group.
We hear from all quarters that opioid abuse is a national crisis. In contrast with the drug addicts of former times, who were regarded as something like common criminals, individuals who have fallen prey to opioids abuse are frequently seen as unfortunates who are in need of treatment, particularly if their initial exposure to opioids was as pain medication and not as a recreational drug. The problems that recreational drug users present to society are not viewed sympathetically. We know of a young woman who was seen exchanging the food stamps (on which she relies to feed her two young children) for a packet of opioid pills. To the best of our knowledge, her introduction to opioids was not as treatment for pain, but as a party drug. Some form of treatment is required for her, without doubt, but she is not part of our quandary.
That’s a far cry from the way the many individuals who fell into opioid abuse following severe pain episodes are currently seen. The (fictitious) case histories below may explain why this is so.
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Case history number one: Manny
Manny is a healthy, fit male of about forty years of age. He drives a truck for a company that supplies water-softeners to homes and small businesses, and he delivers water softener salt, in forty-pound plastic bags and also in steel cylinders that weight upward of a hundred pounds. He normally carries two bags at a time – one in his right hand and the other over his left shoulder.
One day, while making a salt delivery to a regular customer, he slipped on the stairs leading to the cellar where the water softener was situated and fell to the cellar floor. No matter how he tried, he could not get up from the floor. The customer tried to help, but to no avail. The ambulance crew had a hard time getting Manny up the cellar steps, while Manny writhed in agony.
When they got Manny to the hospital, the good news was that no bones were broken, and he had managed to avoid a concussion. But he had sustained a severe sprain of his left ankle, and some of the ankle bones were dislocated, causing tears in the bursa, which are the envelopes that hold them in place and prevent friction.
After a few days in the hospital and two weeks of physical therapy, Manny could move around a bit, with the aid of crutches and an ankle brace. But it would be a while before he could go back to work.
In the meantime, he was in pain a good bit of the time. In the hospital, he had been given a combination of pain killers, including opioids and acetaminophen (Tylenol). He was also given a prescription for a time-release opioid – enough, according to the hospital physician, to carry him through the two weeks of physical therapy, after which the recommendation was that he could switch to an over-the-counter pain killer, such as acetaminophen or a non-steroidal anti-inflammatory drug such as ibuprofen or naproxen.
The opioids Manny was prescribed took the edge off the pain, but not much more. He figured he could live with it. However, when the prescription for the opioids ran out, he found that the OTC pain killers did very little. He telephoned the hospital where he had been treated and asked to speak with the hospital physician. He was only able to leave a message for the physician, saying that he was still in considerable pain, and asking whether the prescription for the original opioid pain killer could be refilled, since that medicine at least seemed to help to some degree. In response, he got a telephone call from a nurse saying that the prescription could not be refilled, and suggesting other remedies such as ice packs in addition to the OTC medications.
At this point, Manny began getting pressure from his employer to go back to work. In response, Manny told his boss of his plight – that he was still in considerable pain, and the doctor would not renew his prescription for the drug that seemed to help. His boss made what seemed to Manny at the time a very helpful suggestion: the boss knew of a local pain clinic that specialized in cases such as Manny’s – helping people overcome pain problems so that they could “get on with their lives.”
Manny went to the pain clinic, where he was given another opioid – this time not a delayed release opioid, but immediate-release oxycodone, whose effects he began to feel more quickly, within about 20 to 30 minutes. He also had weekly physical therapy appointments at the pain clinic.
Thus provided, Manny figured he could go back to work.
For the first few days, Manny took his pain killers exactly as prescribed. The pain didn’t go away, but it was better, and he was able to cope with the demands of his job, carrying the 40 pound bags of salt, and being especially careful on cellar steps. But one day, the pain got to be a bit too much, and he took his next ration of pills a bit earlier than scheduled. Then, on another day, instead of taking two of the 5 mg pills, he took three. And he felt better. And then, on another day, he took four.
When he noticed that his supply of pain pills was running low, he headed back to the pain clinic and asked about a refill. No problem. The pain clinic dispensed medications directly. And when this happened again, again there was no problem.
Six months after his accident, Manny was still taking opioids, but now the quantity of opioids he was taking was about three times greater than the amount he had been given when he left the hospital. He was almost completely recovered from his accident, but he was reluctant to cut out his pain pills completely. He occasionally felt twinges of pain, and it didn’t seem as though his pills were doing him any harm. In fact, all in all, he felt pretty well. After a hard day’s work, his pain pills helped him relax.
Manny had certainly heard of opioid addiction, but he was quite sure that he himself was no addict.
Case history number two: Moe
Moe is in his mid-fifties. He’s a high-school football coach, and he played football in high-school and college. He’s big and strong and tough. But for the past several years, his knees have been giving him considerable trouble, and the palliative treatment he has been receiving – steroids and lubricants injected into the joints – have stopped helping. He really can‘t continue to manage his job as a football coach if all he can do is hobble around the field. He figures he took a lot of punishment as a young man, and his excess weight didn’t help. So, with the advice of his doctor, he has decided to have total replacement of both joints at the same time.
His doctor wants him to be aware that doing both knees at the same time makes the recovery process more difficult, and warns him that the most difficult time for him will be the months immediately after the surgery. He will need intensive physical therapy to recover the ability, both to bend his legs and to straighten them, and the physical therapy invariably causes pain, so he has to be prepared for that.
Moe is confident that he can stand pain. He played football, he sustained injuries, he’s not a sissy.
The doctor is willing to go ahead with the double knee replacement based on Moe’s assurances that he’s prepared to deal with whatever comes along. But he is also somewhat apprehensive regarding Moe’s ability to handle the necessary pain medications he will need. The doctor knows that Moe is not abstemious when it comes to strong drink. He is one of those men who drink stout ale and go to bed quite mellow. Moe thinks of himself as being able to handle just about anything, including strong drink, and probably also, strong drugs. Moe is not going to be cautious and sparing with regard to his pain medication. Therefore, the doctor is going to be conservative with Moe’s post-surgical drug regimen.
The surgery itself was uneventful, and during the first couple of days in the hospital, Moe had no real problem coping with his pain level. When Moe was transferred from the hospital to a residential rehabilitation facility, the pain medication prescribed for him by his doctor was hydromorphone (Dilaudid) at the lowest dose, along with other analgesics – acetaminophen (Tylenol), and an NSAID such as naproxen. And the pain came on strong!
Moe was more than a bit conflicted during his first few days at the rehab place. He thought of himself as a tough guy, able to handle pain. But the pain was quite a bit worse than he had anticipated. He did not want to whine and complain to the nurses, who were treating him with the greatest kindness. He made up his mind to grin and bear it.
After the third night at the facility, during which he got very little restful sleep, his resolution broke. When the nurse appeared in his room in the early hours of the morning to check his vitals and give him his first round of medications, he told her that he didn’t think the pain medications were working all that well, and begged for more – either a higher dose, or a more effective pain pill. The nurse, of course, referred this to the resident physician at the rehab facility, who came to Moe’s room and had a little chat with him. This physician discussed a range of non-drug interventions, starting out with ice packs, but made it clear to Moe that he could not change the prescription or increase the dose without the approval of the surgeon who performed the procedure.
Moe hoped for the best.
The resident physician then had a talk with the surgeon, who was highly reluctant to change Moe’s pain medication regimen. His reasons were precisely that Moe had expressed total confidence that he would not become addicted to opioids. Moe had an extremely low opinion of drug abusers of any kind, and total confidence in his own ability to deal with opioids. Moe’s over-confidence presented a threat. The two physicians agreed that in all likelihood, Moe’s pain level would decrease over the next few days, and he could get through that period with the medications he was taking, plus some intermittent icing and gentle physical therapy.
The next ten days at the rehab facility were not fun. The physical therapy sessions were torture. He slept very poorly, and was in considerable pain nearly every moment. After the first few days, he graduated from being transported in a wheelchair to getting around by himself with a walker. He saw, however, that other people in the facility were getting around using only a cane, and he questioned whether he had made a mistake in getting both knees done at the same time.
When he was discharged from residential rehab, he was given a prescription for the same pain medication, which he was instructed to take three times a day. The prescription was for a ten day supply.
At the end of three days, he had exhausted the ten day supply. He telephoned his doctor for a refill. And, to Moe’s surprise, the doctor was anything but accommodating. The verdict was that he would refill the prescription for another ten days worth of the pain pills, but the new prescription would have to last the full ten days. It would not be refilled prior to the ten-day marker.
At this point, Moe’s wife enters the picture. She has been increasingly concerned about Moe – not only his progress after the knee replacement and his nearly constant pain, but his state of mind. Moe is depressed and short-tempered. His usual optimistic affect has evaporated. Moe’s wife confides in her best friend, who also happens to be the wife of Moe’s assistant coach, the football team’s trainer. And her friend tells her that getting pain pills is no problem at all. He husband has plenty, because he doles them out to injured players on the football team.
Moe’s problems, for the moment, are solved. His assistant coach can supply pain pills as needed. Moe’s recovery from the knee surgery picks up speed, his pain level drops markedly, and his overall disposition changes from bleak to sunny. There seems to be no problem with a continuing supply of pain pills, and all is well.
How long Moe will continue to take large doses of opioids is completely uncertain. He could taper down as his pain levels recede. Or he could become addicted.
Case history number three: Jack
Jacqueline, known to all as “Jack,” is a sixty-year old self-employed graphic designer. Like just about everyone, she had chicken pox as a kid, and like lots of people who had chicken pox as kids, she developed a severe case of shingles some fifty years later. But, like a fairly small minority of persons who are afflicted by shingles, she went on to be assaulted by an extremely painful case of postherpetic neuralgia.
The clinical details are well known. Chicken pox is caused by the varicella zoster virus. The chicken pox episode is bothersome, but not dangerous. Kids are warned not to scratch, because scratching the itchy little pustules will likely lead to scarring. Aside from that, chicken pox is not much more than an excuse to miss school for about a week. Except that the varicella zoster virus doesn’t go away – it stays in the body, and in about one percent of individuals who have had chicken pox, it re-emerges as shingles, which is a condition in which the virus travels along nerve pathways, affects more or less the same kinds of skin cells as the chicken pox did, forming rashes and little pustules. But the chief difference between chicken pox and shingles (or herpes zoster, as it is officially referred to) is that shingles can cause really severe pain. Estimates are that about one million persons a year in the United States are affected by shingles.
Initially, shingles is usually treated topically, sometimes by the application of soothing lotions such as calamine to the affected area. If the pain persists after the initial rashes recede, topical analgesics such as lidocaine patches may be used on the affected area. Systemic antivirals (acyclovir, famcyclovir) are also used to quell the virus, and steroids may be used to dial down the immune response.
But in a minority of cases, the activity of the herpes zoster virus persists as postherpetic neuralgia. This is a really nasty condition that can cause severe pain that may last for months, or even longer. And that’s what landed on Jack.
Jack had consulted a dermatologist when she developed shingles and continued under the dermatologist’s care when shingles morphed into postherpetic neuralgia. The derm initially treated Jack with an antidepressant, amitryptaline (Elavil), in addition to the lidocaine patches which had alleviated the shingles pain to some degree. After about six weeks of treatment with the antidepressant, Jack found that she was perhaps having problems with the drug – her heart was beating abnormally fast, and she was almost always unpleasantly aware of it.
Jack’s dermatologist then prescribed pregabalin (Lyrica), a drug originally developed as a treatment for seizure disorders such as epilepsy. Pregabalin is essentially a more effective version of gabapentin (Neurontin); both pregabalin and gabapentin were developed and marketed by Pfizer. These drugs were found to be effective treatments for nerve pain, and thus appropriate for postherpetic neuralgia.
However, Jack’s health insurance company presented a major obstacle to the pregabalin prescription. Her doctor would have to certify that several other drugs had been used prior to approving pregabalin. Approval would likely be slow in coming, even after the derm had filed the necessary paperwork, and in the meantime, Jack’s nerve pain would continue unabated. And even if the pregabalin prescription were ultimately approved, Jack would have to shell out considerable money in co-payments – about $500 per month, which she didn’t think she could afford.
Jack’s response to this was, “Why on earth would I have to go through this? Isn’t there something else you could give me that could take care of this awful pain?”
The derm then tried a prescription for Suboxone, which is buprenorphine with naloxone, a reasonably effective pain killer compounded with an anti-addiction agent. It was similarly denied.
In the meantime, the derm had given Jack a prescription for OxiContin, which he gave her with the proviso that he didn’t want her to stay on that drug for an extended period, but it would help her cope with her elevated level of pain until he could get a more appropriate long-term treatment approved by her insurance company. OxyContin is a controlled-release form of oxycodone, appropriate for persons with chronic pain, but formulated in such a way that it does not produce the immediate sense of gratification that the immediate-release oxycodone supposedly gives the opioid-addicted.
The OxyContin worked pretty well for Jack. After a few days, her pain had dropped to a tolerable level. She told the derm that she saw no reason to keep looking for something different. She was okay with OxyContin.
The derm agreed to continue the OxyContin prescriptions, with the warning to Jack not to exceed the recommended dose. His long-term concern was that postherpetic neuralgia can go on for a year or even longer, and that the Jack’s response to the pain medication could very well diminish over time, such that she would simply up the dose on her own. He anticipated that she would come back to him to renew her prescription at increasingly shorter intervals, and that, despite his worries over the possibility that Jack would become addicted, he would have very little option except to go ahead and provide her the needed pain medication.
Will Manny, Moe, or Jack become opioid addicts?
The great likelihood is that they will at least become habituated to their opioid medications. Manny, after six months on a high daily dose of an opioid, is already habituated. Up to this point, he has not taken a sufficiently large single dose of his preferred opioid to give him the kind of “opioid high” that addicts crave, and, fortunately, he has not taken a large enough dose to risk an overdose reaction. But he’s on the edge. He might try something risky.
Moe and Jack present similar problems. Moe has no objection to being just a bit “tiddly,” – which is to say, he enjoys the effects of mild alcohol intoxication. Given the easy availability of opioids from his assistant coach, he, too, might try something risky.
For Jack, the basic question is, how long will her postherpetic neuralgia persist? The sooner it subsides, the better her chances are of totally escaping addiction. Her derm will continue to urge her to scale back the dose, and she will likely continue to be under the care of a caring and involved physician, unlike Manny or Moe. Remember, in Manny’s case it was the need to go back to work that sent him to the pain clinic, and in Moe’s case, it was the somewhat rigid physician that gave him little choice but to go outside the medical system. Jack stands a better chance, as long as she continues to consult with her derm.
But, without question, it is a real quandary. Patients in pain require treatment, and the most effective treatment options can be addictive.
What about those people who abuse opioids for recreation?
It is certainly the case that some of those individuals, who began using opioids for pain management, develop a craving for the sensation they experience as the opioid takes effect, and progress to being full-fledged junkies. This is what terrifies the medical establishment and leads, in some cases, to the under-treatment of pain. But there is another cohort, evidently quite large, that simply takes opioids for pleasure. Recreational opioids came into wide use as a “party drug” because, at least initially, they were free from the lower-class onus of “street drugs” such as heroin, crack cocaine, and the like, and they didn’t have to be purchased from unsavory characters who were obviously crooks. They were legitimate prescription drugs, and the people who diverted these drugs from legitimate channels were doing nothing more than offering people something that would help them have a good time.
But, in order to get the desired sensation from the opioids, recreational users may need to overcome the safeguards that the pharmaceutical companies have tried to incorporate into the opioid formulations. So they pulverize the delayed-release pills and inhale the opioid through their noses, or dissolve the pills in liquid and inject the solution, so as to deliver an immediate hit. Experts maintain that no opioid formulation that is intended to deter abuse is immune from the kind of tampering that overcomes the intended deterrence mechanism.
A lethal newcomer to the opioid category is fentanyl. Fentanyl is actually not a newcomer, having been around for half a century or so, and having been legitimately used as an anaesthetic and in the form of quite effective pain-relieving patches. It’s at least 50 times more potent than morphine, and some fentanyl analogues are up to 10,000 times more potent than morphine.
The potency of fentanyl doesn’t make it inherently dangerous, if it is used with extreme care, meaning that the dose used is proportionate to its potency. Whereas the dosage of other opioids is generally given in milligrams, that of fentanyl is given in micrograms. Of course, that potency makes it relatively easy to overdose.
What makes fentanyl potentially lethal is that it’s the ideal medium for drug traffickers. They can sell tiny amounts for a lot of money. They don’t need to smuggle suitcases full of the stuff to make a killing. And it’s relatively easy to synthesize, meaning that there are illicit labs turning out fentanyl just about anywhere in the world. The quality and purity of the stuff the traffickers are peddling is a black hole, and it’s frequently adulterated with other substances, including heroin.
Another factor that contributes to the menace is that fentanyl is said to result in less feeling of euphoria in users as compared with heroin. Instead of the heroin high that the drug users desire, what they feel is sedation and somnolence. And that, in turn, leads to overdosing. “Maybe I just didn’t give myself a big enough dose,” the users say to themselves. And the next dose kills them.
In case you didn’t know …
… what the symptoms of an opioid overdose are: one simply stops breathing. Even moderate doses of opioids depress respiratory function, and when the dose goes high enough, the parasympathetic nervous system just turns off, and breathing slows to a halt. If victims are not revived in time, guess what?
Opioid overdoses can be reversed by agents that are antagonists at the μ opioid receptor such as naloxone (Narcan) and others. These agents are injected or delivered intranasaly, and frequently multiple doses of the agent are needed, because the effect of opioid itself lasts longer than the effect of the antagonist.
Although the naloxone itself is inexpensive, the delivery systems that are provided to police and emergency responders are far from inexpensive, and some small communities where opioid abuse is common are finding that the cost of these kits is a considerable burden on their budgets, sometimes crowding out other equally vital needs. An egregious example is an auto-injector kit similar to the EpiPen. A single use device lists for $2,250. The value of the auto-injector is that a totally untrained person can use it, making it appropriate for emergency use by any bystander. Some activists have proposed that these kits be available in public places, so that any person experiencing an opioid overdose can immediately be given emergency treatment. The idea has not caught on, can’t think why!
What about the “glimmers of light” that Doc Gumshoe referred to earlier?
There’s no room in this installment to describe them, but here’s a hint: there are several ways of managing pain without the use of drugs that have been effective for some patients. And there’s an opioid currently approaching FDA approval that is – based on solid evidence – fundamentally not susceptible to abuse. How can this be? I’ll explain in my next post.
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I keep being surprised and gratified when Doc Gumshoe posts from several months back keep attracting new comments and new controversies. Many thanks for all comments, whether in agreement or the contrary. Best to all, Michael Jorrin (aka Doc Gumshoe)