In the weekend review from ACEP, two articles caught my attention. The first one was on new guidelines from the American Society of Addictive Medicine on the use of prescription medication to treat opioid addiction. These guidelines were created soon after the Centers for Disease Control and Prevention (CDCP) declared opioid use and resultant death as an epidemic. The second article refers to a study showing that pain is underdiagnosed and undertreated in the ED. This is the challenging dichotomy we live and work in.
On the one hand, most of us entered the medical profession to improve the health of others and alleviate suffering-- pain is a large component of that. Uncontrolled pain can lead to stimulation of the sympathetic nervous system, an increase in heart rate and blood pressure. It can also lead to decreased GI motility and a depressed immune system. On the other hand, there is an opioid addiction epidemic in this county. Opioids are synthetic pain medications produced to have similar effects to opiates. Some common examples of opioids are Vicodin, Percocet, Dilaudid, and Methadone. According to the CDCP, 46 people die every day from overdosing on prescription pain medication. There were 259 million prescriptions written for pain medication in 2012, more than one bottle for every adult living in the US. This has become a huge problem, and one with no easy solution.
Several compounding factors make the issue even more complex. As Victor Hugo noted, “Pain is as diverse as man. One suffers as one can.” The experience of pain is so unique that attempts to classify and categorize it fall woefully short. Currently, most hospitals use the 1-10 scale to measure pain, but we would probably be much better off asking someone how much pain they are in. The second compounding factor is public perception. What percentage of pain relief is adequate and how long should that take? In the instant gratification society we live in, the answer, many times, is 100% and right now! This is simply an unrealistic goal leading to the patient and physician expecting different outcomes. A third factor is the underappreciation for the side effects and addiction potential of opioid pain medication. Closely related, I believe, is an underappreciation by both physicians, and more so the general public, of the effectiveness of acetaminophen and NSAIDS.
What is the solution? In short, there is no easy one. There are moves, however, that we can take to both alleviate suffering and curb the opioid epidemic. A healthy respect for the addictive potential of opioid pain medication is a good start. Moreover, the side effects that occur, especially for people on long-term opioid pain medication need just as much awareness. Non-opioid pain medication, for those who can tolerate it, is a good alternative. Prescription medications such as Gabapentin and the SSRIs can also play a role. There are many alternative treatments that can also help in pain relief including massage, acupuncture, OMT, chiropractic treatment, meditation and exercise. If opioid pain medication is appropriate, it should be used in the lowest effective dose and for the shortest time period possible.
Finally, we must work with the public and our patients to come to realistic goals and a mutually agreed upon treatment plan. Pain from a sprained ankle can be severe, but like any other medication or procedure, there are risks and benefits to weight when treating with opioid pain medication. The pain from a sprained ankle will get better over time, even without pain medication. Is temporary relief of pain while waiting for the body to heal itself worth the risk of a life-long addiction problem? I guess that’s the real question, isn’t it?
Ryan McKennon, DO with Ren Carlton