Managing pain in the age of opioids

Managing pain in the age of opioids – by Greg Johnson – Feb 2020

This author seems to believe the propaganda that pain patients all having opioid use disorder, but I can ignore that because he makes another important point: if we had true access to a wide variety of treatments for pain care, opioids might be less necessary for some people sometimes.

However, many non-prescription treatments require repeated sessions, raising the costs for insurance companies who much prefer paying for a bottle of monthly generic opioid pills instead of weekly therapy sessions for a lifetime.

By now, I expect everyone who can do without opioids has been tapered, along with countless others who cannot do without and are hunkering down waiting for this country to regain its senses and stop this misdirected, ineffectual, and cruel prohibition of pain medication. 

Martin Cheatle, director of behavioral medicine at the Pain Medicine Center and an associate professor of psychology in psychiatry at HUP, says pain care in the United States has “devolved, not evolved.”  

In the past, patients would have access to an interdisciplinary pain program that would offer a multimodal approach to improving their pain and quality of life, which would include physical therapy, occupational therapy, medical care, behavioral health, nutrition, and medication trials.

In the late 1990s, there were approximately a thousand of these interdisciplinary pain facilities across the country—but he says there are only about 20 to 30 still in operation due to  health care reimbursement issue.

…the Center has been working for years on developing a closer relationship with their physical therapy and occupational therapy partners, and exploring innovative ways of providing physical therapy services to patients as close to home as possible. 

Opioids in the community

“Most people don’t understand that when we think of the face of opioid addiction, we think of the individual in Kensington who’s injecting,” says Ashburn. 

The vast majority of people who have an opioid use disorder are using prescription drugs for nonmedical purposes,

I would argue that whatever they’re taking, they certainly aren’t opioids *prescribed to those individuals*.

This is the insanity of how the CDC is counting drug overdoses: counterfeit Rx opioids, increasingly contaminated with illicit fentanyl (sometimes in deadly concentrations) are classified as “prescription opioids”.

It’s like comparing bootleg (illicit) alcohol from backyard stills during alcohol prohibition and the alcohol you buy in a liquor store. There were many deaths from bootleg booze until prohibition was lifted and solved that problem.

In looking up the numbers of deaths, I found that bootleg liquor is still killing people where alcohol is prohibited: Bootleg Liquor Kills At Least 150 In India’s Latest Mass Alcohol Poisoning

Dental Care

Dentists are no longer the No. 2 prescribers of immediately release opioids; since their zenith in 2011, they have fallen to sixth.

The oral surgeons of today will typically recommend or prescribe an NSAID for post-surgical pain—but may still, in the most traumatic cases, prescribe an opioid as well. If they do, Hersh says patients should be prescribed a small number for limited duration.

Veterinary Care

Dana Clarke, an assistant professor of interventional radiology at Penn Vet, says opioids are essential for managing pain in animals in the hospital.

Dogs can be given NSAIDs, but are more sensitive to the drugs than humans, especially dogs with liver or kidney disease. Birds and rabbits can be given NSAIDs, too.

They [NSAIDs] are generally avoided in cats however, due to their hypersensitive kidneys and livers.

I couldn’t resist showing you this “Feline Pain Scale”:

Clarke says veterinarians track controlled drugs as well, logging all drugs used with the Drug Enforcement Administration and maintaining accurate records of the amounts and frequency of medications being dispensed for every patient.

Vets do not, on the other hand, have a national database/registry as they do in human medicine to know what is being prescribed to a given pet from state to state.

So, they’re apparently not too worried about owners/pets going doctor/veterinarian shopping.

“A lot of the dogs that I treat with tracheal collapse have to be on hydrocodone for their lifetime to prevent the cough,” she says

“Many people are working on compassionate, healthy, good ways of controlling pain after surgery, while doing everything we humanly can to minimize the chances that we cause harm to the patient, the patient’s family, and the community at large,” he says.

Well then, they should definitely prescribe opioids for human patients who tell them they are in pain after surgery.

Other thoughts?

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