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How can we educate patients (youth and adults) about the risks of opioids?
In preparation for this week's discussion, I wanted to share some resources that might be of interest. We encourage you to share additional resources on this important topic, as well as any questions you'd like to see our panel address over the course of the week. Looking forward to a great discussion!All resources for this Expert Panel can be found at ghdonline.org/opioid-epidemic/resources
Link leads to: http://turnthetiderx.org/
Link leads to: http://www.nejm.org/doi/full/10.1056/NEJMp1208498#t=article
Link leads to: http://www.wsj.com/articles/tramadol-the-opioid-crisis-for-the-rest-of-the-world-1476887401
Link leads to: https://jhupbooks.press.jhu.edu/content/drug-dealer-md
Link leads to: http://www.cdc.gov/drugoverdose/prescribing/patients.html
People take Opioids because they are effective at least for a while, to treat pain: physical, spiritual, psychological, social, etc. Tackling the "opioid epidemic" means tackling the total pain afflicting some very vulnerable members of our society. Addressing the loneliness, isolation, lack of meaning, lack of employment, lack of meaningful employment, sense of despair about environmental and community destruction, etc. This requires an all hands on deck community approach, along with, of course, overdose prevention, and clinical interventions. But let's not delude ourselves that clinical interventions alone will do the trick. Education for clinicians, of course. Reining in the pharma industry, of course, changing the perverse incentives of the insurance and payment systems, of course, but mainly building resilience and joy into communities, rather than manufacturing and tolerating despair and alienation.
Science provides one of the most powerful ways to educate youth and adults about the risks of opioids. It doesn't do much good to tell people, "opioids are bad for you" or "opioids are addictive". But if you say, "Hey, did you know that opioids, and other addictive drugs, can change your brain?" - that tends to grab their attention. How do opioids change the brain? They alter the set point for experiencing pain, and joy. In particular, chronic heavy exposure to opioids causes the brain to become more sensitive to pain, and to experience less joy ... the exact opposite of why most people start taking opioids in the first place. When that happens, experiences that are normally not that painful, like stubbing your toe, become more painful. Experiences that are normally joyful, like being with friends, or watching a beautiful sunset, lose their joy. In my experience, people who have been taking opioids for a long time relate to this, because they have experienced it first hand. By explaining the changes that occur in the brain as a result of chronic, heavy opioid exposure, we can help people understand on a deeper level why taking opioids for a long time is not a good idea. It just doesn't work.
Good morning! I am excited to talk with you about the cultural, social, and economic forces driving the opioid epidemic, and what we can do to create change for the better. Just this month I published a book, "Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It's So Hard to Stop", which explores this very question.One of the interesting things I learned while researching my book, was the way our conception of pain has changed over time. Prior to 1900, pain was viewed as an immediate and short-lived response to an injury or illness – the body’s emergency warning system that burned bright and then burned out. Once the injury healed or the illness was cured, (or the body just got used to it, whichever came first), the pain, so the thinking went, disappeared. There was no framework or lexicon for chronic pain, especially in the absence of injury or objectively verifiable disease. Today, hospitals and clinics are overrun with patients struggling with a growing variety of chronic pain conditions. Indeed the number one cause of Social Security Disability Insurance (SSDI) today is chronic pain. Compare this with the 1980’s, when the leading causes of disability were heart disease and cancer. Furthermore, pain today need not be caused by an injury or illness. Pain can be its own disease. A growing list of chronic pain conditions has emerged for which there is limited understanding and no obvious medical antecedent: fibromyalgia, complex regional pain syndrome, pelvic pain syndrome, etc.Another aspect of pain management that has changed in the last 150 years, is the approach to peri-operative pain. As recently as the mid to late 1800’s, pain during surgery was considered salutary, by boosting cardiovascular and immune function and thereby expediting healing. By the 1950’s, with advances in anesthesia (methods of rendering patients unconscious) and analgesia (methods of eliminating acute pain), especially the growing availability of synthetic and semisynthetic opioids, pain during surgery was no longer considered beneficial. (Of interest, recent reports have shown that patients who receive opioid painkillers during surgery have slowed rates of tissue healing compared to those undergoing the same surgery without opioids, which may be attributable to opioid suppression of the immune system.)A third way medicine’s conception of pain has changed over time, is pain today is ‘bad’ not merely because it is painful, but also because it is believed to engender future pain, by leaving a neurological scar, so to speak. Such conditions are of-late referred to as ‘centralized pain syndromes’, and localize the source of the pain in the brain, rather than out in the body. As a psychiatrist, I can’t help but note the parallels between centralized pain syndromes and post-traumatic stress disorder, both of which link the acute experience of pain as a potential source of long-lasting pain.The changes in the past century in the way medicine and society view pain have improved the lives of many people with pain; but have also inadvertently contributed to the opioid epidemic, by encouraging doctors to overprescribe opioids for chronic pain, and by making the elimination of all pain the goal of medical treatment. Emerging evidence suggests that opioids are not effective when used long-term for pain (they are very effective for pain short term, i.e. 1-3 days), and chronic opioid use may even cause serious adverse health consequences, including making pain worse when used for more than a month, and impeding the healing process.
Katherine,I agree with you 100%. Medicine and medical treatment can only go so far in curbing the opioid epidemic, and in targeting addiction more generally. On a deeper level this is a serious societal problem, and one that does tap into the loss of community and sense of alienation that many people feel. I have observed some interesting programs within the house of medicine, however, that try to build community among patients as a way to target opioid addiction. The roots of this idea come from Alcoholics Anonymous and the 12-step movement. By using the power of community and peer recovery as tools within medicine, perhaps we can help give patients some of the tools to overcome their addiction.
As a primary care physicians, patients often come into me with complaints of pain for months or years and want me to "take care of it". Or they have an attitude of "we can put a man on the moon, so we should be able to get rid of pain". "What are you going to do about it, Doc?" The anxiety around chronic pain is often as damaging as the pain itself. Individuals with pain often anticipate pain and limit their lives, or they take sedatives or opioid pain medication to avoid feeling the pain. I try to sit with them and witness them holding their pain. there is a fine line between truly diagnostic work/trying new treatments that may help them AND helping them accept their pain and managing life with the pain. this is the art of medicine, and often it is much easier just to write the prescription than it is to do the hard work of acceptance and manage around the pain. Thanks for a great short description of the history of pain and how we got to where we are today.
Dear Jane,Great to connect with you again, after a long hiatus. I agree with you. The labor-intensive work is talking with patients about how to cope with pain. Anyone can write a prescription, and it only takes a few minutes. Whereas getting into the deeper discussion of how to live day to day with chronic pain, is much harder. Which is why it is so important for the health care system to reimburse/reward doctors for taking time with patients. We can't begin to discuss these complex issues unless we have TIME.
It's worth looking back and seeing how marketing, the pharmaceutical industry and certain pain specialists contributed to the crisis we now have. Although you cannot turn back the clock, it is a lesson in how we spend so much time "fixing" problems that we ourselves created.Back in the early 1980s, narcotics were FDA-approved for patients with severe cancer pain. However, several drug companies wanted to expand usage to non-cancer pain in advance of launching their new narcotic Rx drugs. Industry joined forces with pain specialists that included J. David Haddox, DDS, MD, and Russell Portenoy, MD. These pain specialists sought to expand use of opioids to non-cancer pain and with funding from Purdue Frederick set up pain organizations to advocate for off-label use of narcotics. These organizations published articles in clinical journals stating that pain was under treated in America and that drugs like oxycontin were safe enough for osteoarthritis, migraine and dental pain. Organizations like the American Academy of Pain Medicine and the American Pain Society pressed for the "appropriate treatment for refractory chronic non-cancer pain in the general population as well as in older patients" and also - with industry funding - worked with state legislatures to get this new paradigm into law. This push even had a major impact nationally by their working with the Joint Commission on Accreditation of Healthcare organizations (JCAHO) to set up new standards for pain treatment. At the same time, these organizations - with industry funding - were working at the legislative, regulatory and publishing level, sales reps from Purdue Frederick were going out to primary care offices, saying that oxycontin was non addictive. The company however knew this was not true as was later revealed. Having spent a chunk of my career as a clinical writer in pharmaceutical marketing, the unspoken truth is that industry often seeks to expand use of their Rx drugs, whether or not that use is appropriate. The larger the pool of patients needing drugs, the larger the profits. Physicians can play an important role in promoting appropriate medication use through awareness of industry practices.
Thank you for a great discussion so far on the Opiod epidemic. I would say an added factor contributing to the epidemic is the burden on physicians and other healthcare providers to sequence patients through the system in an "efficient" way to keep up with insurance and other regulations. Hence the need for a quick fix instead of spending time with each individual patient to address the social determinants of health and helping patients cope with chronic pain and diseases.
Lydia and Maimunat,You raise important points about the influence of the pharmaceutical industry and an increasingly industrialized medical system, in the rising number of opioid prescriptions for common medical conditions. I talk about both of these issues in my book "Drug Dealer, MD". The former in a chapter called "Big Pharma Joins Big Medicine: Co-Opting Medical Science to Promote Pill-Taking." The latter in a chapter called "Pill Mills and the Toyota-ization of Medicine."As you point out, Lydia, the pharmaceutical industry took a Trojan Horse approach and infiltrated academia and regulatory agencies such as The Joint Commission, to convince doctors that prescribing more opioids was supported by science ... not true! Big Pharma also influenced the FDA, to make it easier to get new opioids approved. The FDA approved long-acting hydrocodone (Zohydro) in 2013!Maimunat, you appreciate the way that our assembly-line approach to health care has impacted our prescribing. In 2002, 70% of physicians in this country worked for themselves or in physician-owned practices. By 2008 the majority of physicians worked as salaried employees for large integrated health care systems. This migration into centralized medicine has had a gigantic influence on how we practice medicine, including on how we prescribe. Unfortunately, prescribing pills has become a proxy for real attachment. Who's got time for that?!
Dr. Anna, Lydia, Maimunat and JaneThank you for your contribution to this discussion panel. The take home message is that the society as whole has to be educated about pain management. Bearing in mind that opioids are not the only resource available to alleviate the pain. Making patients to understand that opioids can "CHANGE THEIR BRAIN" is a very good approach in finding alternative management of pain. The discovery of new analgesics will also help in non-opioids prescriptions for pain. Everyone has to be involved in this effort so that we can make sure that those suffering from chronic pain get the right help they deserve.
Pierre, I agree with you!Thank you all for the thoughtful discussion.Warmly,Anna
Hello Anna and others contributing to this panel..Thanks for your work in addressing the Opioid Epidemic (Saw your presentation to the E&C Committee in congress and opinion piece..hope to get to your book in the future) Would like to share some links to project I'm working on addressing the Pain Opioid Epidemic ... Hope to make it public soon..http://shimonwaldfogel.wixsite.com/the-opioid-epidemic/about-?draft=trueHere is link to "Treatment Plan" addressing various aspects of the complexity of the Pain Opioid Ecosystem http://shimonwaldfogel.wixsite.com/the-opioid-epidemic/treatment-plan-Any input would be appreciated...With gratitude ;Shimon In case you didn't hear Macklemore's new song Drug Dealer... worth a listen (Accessed over 11 million times on You Tube and over 12,000 comments so far..) Here is link to MACKLEMORE - DRUG DEALER https://youtu.be/fYN14UfO-UcRespose by Carl Hart & Kristen Gwynne http://theinfluence.org/macklemores-song-drug-dealer-demonstrates-his-damagin...
Shimon,What fabulous work you are doing with your grass roots Citizens4Health project. Way to go! I agree a multi-pronged approach at all level of society is what is needed to combat this problem. Keep up the great work.Anna