Over the past year, I have had many patients come to our clinic quite discouraged over the escalating government regulation on the prescription of opioid medications. They are quite concerned that they are going to have their “pain pills” taken away and left to suffer in endless pain. With nearly 15,000 deaths per year in the United States attributed to opioid pain medications, the government stance is more than justified.
Fortunately, I believe that it is a major misconception that prescribers will be faced with the difficult decision of choosing between less pain control with fewer opioids or more death with increased use of these medications. Most literature supports improved pain control with opioids up to three months, but actually notes that people have less function or physical activity with these medications over the long term. We now realize that if these medications are raised above certain thresholds they not only decrease physical activity, but also increase the risk of death.
In order to reach better pain control with fewer opioids (and therefore fewer deaths in society) we need to change our entire thought process about the treatment of pain. We cannot continue under the delusion that we can pop a pill, mask the pain and move on with life. Patients need to be active participants in the recovery or treatment process.
I have taken care of patients with chronic pain for the past decade. The biggest predictors of how well a patient responds to treatment are positive attitude and a willingness to actively participate in the recovery process. By actively participating, I mean willing to go to physical therapy, the chiropractor, the surgeon, or the pain specialist to receive proper treatment. Patients must also have the will power to change their lifestyle through dietary changes and cessation of smoking, excessive alcohol, or illicit drug use. Underlying depression or addiction should be treated by a psychiatrist or psychologist as it may be hampering the motivation for recovery.
We also need to realize that “pain pills” should not automatically equate to opioid medications. The definition of “pain pills” needs to be broadened to include anything that will improve pain control and enhance physical function over time. The moderate and careful use of opioids often does play a role, particularly early on in the course of injury. However, over time they need to be weaned and titrated down while long term medications including antiinflammatories, anti-convulsants, and anti-depressants are titrated up if necessary. As for those individuals that have been on high dose opioids for years, sometimes even decades, we now have methods to reduce their dose without allowing their pain to spiral out of control or cause extreme withdrawal symptoms.
All of these solutions require the very best of relationships between health care providers and patients. Patients must trust that their doctor, therapist, chiropractor, or nurse practitioner has their best interest for a safe effective treatment plan. The health care providers also must trust their patients to take their medications appropriately and actively participate in recovering their health and well-being. When either party in this relationship communicates poorly or acts in a manner that violates this trust, successful treatment cannot be achieved.
For the past several years, there has been a lot of focus on patient satisfaction, but in medicine we take very seriously the principle of Primum Non Nocere (Latin for “first, do no harm”). We must try our best to reduce a patient’s pain, but in a manner that is ethical, safe and within the limits of laws established to guard the safety of patients and society.
Dr. Shah and Dr. Scarlett are physicians at Advanced Pain Management and practice in Sheboygan, Manitowoc, Fond du Lac and West Bend.