Op-Ed: Opioids, Used Properly, Can Help End the Opioid Crisis | Medpage Today by Errington C. Thompson MD – September 08, 2016
To my knowledge, there has not been a cohesive strategy devised for how to combat narcotic abuse, but simply telling physicians, as the FDA and CDC have done recently, not to prescribe narcotics is not the right answer.
Whether or not chronic pain could be better controlled without the use of narcotics is debatable, but physicians have an obligation to control acute pain, and narcotics must be in a physician’s armamentarium if we are going to do so and meet our patients’ expectations, which is to control acute pain, and quickly.
Once we assess a patient’s acute pain level and why it is there, physicians can call upon a relatively long list of medications of differing classes that address the various components of pain.
- anti-inflammatory drugs like ibuprofen,
- anti-anxiety drugs,
- muscle relaxers,
- epidural anesthesia,
- nerve blocks, and
are just a few of the classes of drugs that can be used to treat acute pain.
Each one of these classes of drugs manages specific, but limited aspects of the pain complex, and each has a laundry list of side effects, which are well known to physicians.
There are multiple narcotics that can be used to control pain.
Narcotics act quickly.
If the physician can choose the right narcotic at the right dose, a patient who has excruciating pain can be comfortable within minutes.
The challenge, of course, is that all narcotics can be addictive. Narcotics have other side effects as well, including nausea, vomiting, dizziness, somnolence, impaired judgment, and low blood pressure.
Yet, their rapid onset and ability to adequately relieve acute pain make narcotics indispensable
Facing a patient with acute pain, what is the physician to do?
For the most part, patients would like for their pain to be controlled within minutes of arriving at the hospital. No patient wants to wait 24–48 hours before his or her pain is adequately controlled.
Thus, in my practice, I aim to control a patient’s pain in the ER and find that for about 90% of my patients, I am able to do so with a combination of muscle relaxers, acetaminophen, and narcotics.
The side effects from this combination are usually minimal.
When a patient arrives at the hospital in acute pain from trauma, I can generally expect that she or he will require some combination of medication, and for several days, sometimes for several weeks, depending on the cause and intensity of pain.
Like acute pain, chronic pain is real; its management is as complex as the pain itself. But it does need to be managed effectively, and it is important to recognize that not all chronic pain patients become addicted to narcotics.
Chronic pain patients who do become addicted to narcotics often appear to “need” them early on more than other patients do. As time marches on and as their injuries heal, these patients do not seem to be able to wean themselves off of the narcotics.
But here is a conundrum, some patients, 2-4 weeks after injury, begin to require more pain medication instead of less.
We need to exercise caution here. It would be easy to label all patients who require more pain medication as chronic pain patients who have become addicted to the medication, but, unfortunately, this is not the case.
Some patients — a small number — require more pain medication because they are actually doing more. They are moving more, they are working better with physical therapy, and so on.
As we try to tackle the prescription narcotic epidemic in the United States, we need to remember that there is distinction between acute pain and chronic pain. The treatments are also different.
We need to remember that not all sufferers of chronic pain abuse medication.
We need to recognize that narcotics, along with other medications — muscle relaxers, nonsteroidal anti-inflammatory drugs, and anti-anxiety medications — are perfectly appropriate and necessary for controlling acute pain. In patients suffering from chronic pain, medicine has yet to find the right solution to this terrible problem.
It is critical to recognize that all chronic pain is not the same and therefore cannot be treated in the same way.
Yet the CDC has stipulated arbitrary dose limits, as though all individuals were the same.
Chronic pain from cancer, for instance, should not be treated in the same way as chronic pelvic pain or chronic back pain. Narcotics are probably appropriate in a dying cancer patient who has chronic pain but, as with all medications, the risk and benefits to that particular patient must be balanced.
A discerning physician, assessing the severity of the patient’s symptoms and the patient’s expectations, will address this balance while at the same time aiming to control the patient’s pain with a full armamentarium of therapeutic modalities.
Solving this nationwide narcotic epidemic will require the cooperation of many, including faith-based organizations, community organizers, law enforcement, government officials, and the smartest minds in healthcare
In the meantime, physicians require narcotics in their treatment toolboxes in order to adequately address acute pain, in a timely manner, and with the hope of mitigating it so that it does not become chronic pain.
This brings me back to my ER patient with the acute pain and no satisfactory relief: it took about two hours, but I was able to control this patient’s pain with a combination of short-acting and long-acting oral narcotics, plus muscle relaxers and acetaminophen.