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Pain Management

The High-Flying Dilemma Chronic Pain and Addiction Murtuza Ghadiali, MD, and David Pating, MD

For the past two decades, the clinically indicated use of opiates has been framed by two competing mandates: the need to effectively treat pain and the ever-increasing need to prevent addiction and overdose. Beginning in 1995, the newly formed American

Pain Society set out guidelines to improve the management of pain, stating, “ . . . if pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated.” In 1999, the Veterans’ Administration mandated the self-assessment of pain as “the fifth vital sign” in an attempt to improve quality throughout its 1,200 nationwide facilities. Since then, many governmental bodies, including the Medical Board of California (2007), have not only mandated training for the management of pain but have also encouraged physicians to actively treat pain with opiates. Yet, as the recognition and treatment of acute and chronic pain grows, so too has the demand for prescription opiates. Riding the coattails of this national love affair with pain medication, pharmaceutical companies have obliged the public’s demand for opiates by providing a liberal supply of stronger and longer preparations, including the highly abusable opiate OxyContin. OxyContin is now the second-leading drug of abuse in the U.S. Taken together, misuse and abuse of opiates is an unprecedented epidemic, resulting in more than 40,000 overdose deaths in 2011, exceeding the number of annual 22 23

San Francisco Medicine April 2012

deaths from auto accidents. As addiction experts, we see this proliferation of opiates as a major public health problem. This problem has multiple underpinnings. First, the unbridled, consumer-driven demand for opiates has not been balanced by adequate evidence-based pain management strategies. In addressing the “vital sign” of pain, even pain experts do not agree whether opiates are indicated for such conditions such as chronic headaches, fibromyalgia, menstrual cramps, and even nonrheumatoid arthritis, particularly if the real goal of treatment is functional improvement, not just relief from pain. Second, on the supply side, pharmaceuticals have enormous incentive to recoup their deferred drug development investment. When large manufacturers, such as Purdue Pharma, makers of OxyContin, hit upon a cash cow, they are amply rewarded with the opportunity to make billions. This, combined with unregulated pharmaceutical sales over the Internet that allow the purchase of nonprescribed opiates with the click of a mouse, has created the current environment: a drug addict’s paradise. Florida is now the leading U.S. supplier of OxyContin to the rest of the country, most of it used for nonmedical “recreational” purposes. As addiction physicians charged with helping patients in trouble with the dual issues of pain and addiction, we see a complicated entanglement of different interests in which doctors are caught in the middle. A patient came to us after “being cut off of meds by her doctor.” She came with MRI in hand, talking about her need for half a gram of OxyContin a day “just to hug her small child at night.” She didn’t understand why her family was concerned (although after drinking wine every night with her dinner she was completely incoherent) and why they wanted her to “get help.” Our first visit was a long and difficult consult, but it ended in her deciding to come for outpatient addiction treatment and get a chronic pain consult. After consulting with the chronic pain physician, we decided to start buprenorphine for pain, which ended up working well for the patient. The therapists found her very resistant at first www.sfms.org


April 2012