If you don’t think pain and its treatment is an issue, then look no further than many of the patients and celebrities (e.g. Heath Ledger, Philip Seymour Hoffman, Andy Irons, Prince Rogers Nelson) who have died from addressing their pain with opioids. From 1999 to 2014, more than 165,000 people have died from opioid overdose, which in many instances is a combination of opioids, benzodiazepines, and/or alcohol.
Unintentional overdoses are now the leading cause of accidental death that has now surpassed motor vehicle accidents.
And although there is a huge surge of illegal production and distribution of opioids in the form of carfentanil, heroin, and others, there is no doubt that a massive influx of opioids into medicine cabinets are due to physicians writing the prescriptions. (See DEA Warning about carfentanil posted on 9/23/2016 at https://www.dea.gov/divisions/hq/2016/hq092216.shtml)
Opioids not only can lead to death; but, they can generate misuse, abuse, and addiction in certain individuals. This struggle is highlighted with the recent release of Macklemore’s Drug Dealer video:
One in four people who receive opioids battle with addiction and there is a lack of resources to help those suffering from it. Nearly 2 million Americans were dependent on opioids in 2014. Every day over 1,000 people are treated in the emergency room for misusing prescription opioids. No matter if opioids help some people cope with non-cancer pain, the risk of life itself and the quality of that life will always remain, regardless of why opioids are taken.
There is a time and a place for opioids, predominantly for acute pain or trauma including surgery and also for cancer. But here is the bigger and more important question:
Why do physicians continue to write so many opioid prescriptions for non-cancer pain despite the risk?
The reasons are numerous and include fragmented and inadequate pain education. The savviest of patients know that opioids do not fix the problem and that they come with potential adverse effects. Yet, the focus of conversation in society is on the acute management of reversing an opioid overdose with naloxone or non-medical entities trying to dictate or regulate the opioid prescribers’ practice of medicine.
Focusing on the dark side of opioid use can seem like a worthy venture to rally behind, but it becomes smoke and mirrors without addressing the underbelly of our nation—pain and suffering.
Opioid over-fixation by society can be the proverbial dog chasing its tail.
Poor pain management is not a lack of acute overdose treatment nor is it a lack of government regulation of the practice of medicine; it’s a lack of deeper understanding of pain and its biological, psychological, and sociological underpinnings at all levels. For if we could more accurately diagnose pain, then we would not be just treating symptoms. Fundamentally speaking, if you focus on symptoms as the problem, then the drive to truly understand the etiology or root cause is hindered.
The perplexing phenomenon of pain is further complicated by the strong innate human drive to avoid pain definitively and quickly. This puts humans in a vulnerable position—one in which pharmaceutical industries have capitalized on and also physicians who have sold procedures and surgeries to patients in the name of “fixing” pain. Patients are at the mercy of the direction they are taken by the medical system; if society focuses on symptoms, then the patients' deeply embedded tendency for a quick fix will just be reinforced and substantiated.
For example, going to a primary care physician who has poor pain education and then referred to a surgeon with the diagnosis of degenerative disc disease (but no emergency issues) will surely not bode well for conservative care unless the surgeon is a proponent of its benefits. There are countless patients who are receiving pain injections chronically as their sole approach to pain management without any understanding of self-care or other options; in fact, most fear pain and avoid activity. This is one of many examples of a setup for disaster. It is society’s ethical obligation to enable patient/provider education and availability and access to the best options that all realms of medicine have to offer. There needs to be a revolution of society’s expectations of pain management (not just a pill, injection, or surgery) and the constitution of more holistic, interdisciplinary pain practices.
*First, rule out true emergencies or urgencies, such as severe neurological compromise, cancer, infection, etc. with a primary care physician or medical professional.
*Accurate diagnosis should be paramount, as poorly diagnosed or misdiagnosed issues will likely be ignored or treated improperly. Chronic pain can result from poorly treated acute pain.
Understand pain is a brain phenomenon that is impacted by the periphery and the central nervous system. Pain is an alarm system that something is not in balance or not quite right, but not necessarily life-threatening.
Self-care follows the understanding that certain behavior patterns can impact pain negatively or positively.
Avoid silo medicine, cookie-cutter medicine, or de-personalized medicine.
Biomechanical evaluation is not taught to most MD physicians in their training:
As a reminder, there can be variability of perspectives, techniques, and practices by any practitioner even within a specialized profession. Second opinions within or across specialties (beyond those mentioned above) may offer other options. Any of the above approaches should be accompanied by educating patients and offering ways or skills for patients to help themselves.
Loose connective tissue (aka fascia) is woven within biomechanics, and tends to tighten with age (elasticity decreases) with the potential for pain. There are multiple ways to address this tissue while also keeping an eye on the biomechanics that affect it. Improving flexibility can have profound effects, including enhanced function and performance of the musculoskeletal system; one of the benefits of practices such as yoga. There are professionals such as those below who can assist with improving fascia, whether gently or more aggressively.
It is important to remember that each “system” of the body does not work in isolation from one another. Thus, the above methods, including acupuncture, tend to impact other systems (e.g. nervous system, immune system, etc.) directly or indirectly to varying degrees. Benefits may extend beyond the initially perceived benefits.
Managing the brain when pain persists despite patient or professionally-aided efforts is just as important as defining the nociceptive input (pain that arises from stimulation of nerve cells) to the brain. There are effective ways to help patients cope with or decrease the brain’s pain experience. Some of the techniques that therapists, psychologists, etc. can use or teach are the following:
To have all of the above and more under one roof for patients would be the ultimate destination for patients to learn and heal, but more work needs to be done to see this become a reality in all corners of the country. Then maybe this country will realize that opioids are truly a last resort for most non-cancer pain.
Pain is a journey in many cases, with a need to address a variety of issues sometimes requiring multiple opinions. As a complex phenomenon, it takes patience from both sides—the patients and those who treat them. Quick fixes with pills will not help instill the behavioral changes or skills needed by so many who are suffering. The real focus should be on creating education, more precision in diagnosis with more strategic treatments, support, and alternatives for those in need—and they need to be available and affordable. It really will take a village for a landslide victory to trump pain!
Resources not mentioned above:
Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2014.
Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction 2010;105:1776–82. http://dx.doi. org/10.1111/j.1360-0443.2010.03052.x
Substance Abuse and Mental Health Services Administration. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. The DAWN Report. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2013. Available from URL: http://www.samhsa.gov/data/2k13/DAWN127/sr127-DAWN-highlights.htm
J.R. Kopp et al, “The Use of Lumbar Extension in the Evaluation and Treatment of Patients with Acute Herniated Nucleus Pulposus: A Preliminary Report,” Clinical Orthopaedics and Related Research, (1986):211-218.
Ron Donelson et al, "Influence of Directional Preference on Two Clinical Dichotomies: Acute Versus Chronic Pain and Axial Low Back Pain Versus Sciatica," PMR, (Sept 2012);4(9):667-81. doi: 10.1016/j.pmrj.2012.04.013
Claus Rasmussen et al, “Rates of Lumbar Disc Surgery Before and After Implementation of Multidisciplinary Nonsurgical Spine Clinics,” SPINE Volume 30, Number 21 (2005): 2469–2473.
John C. Licciardone et al, “Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: A Randomized Controlled Trial,” Ann Fam Med 11, no. 2 (2013):122-9. doi:10.1370/afm.1468.211
John C. Licciardone, Angela K. Brimhall, and Linda N. King, “Osteopathic Manipulative Treatment for Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” BMC Musculoskeletal Disorders 6, no. 43 (2005): 12 pages. doi:10.1186/1471-2474-6-43
Helene M. Langevin et al, “Dynamic Fibroblast Cytoskeletal Response to Subcutaneous Tissue Stretch Ex Vivo and In Vivo,” American J Physiology - Cell Physiology 288 (2005): C747–56. doi:10.1152/ajpcell.00420.2004.120
Helene M. Langevin et al, “Ultrasound Evidence of Altered Lumbar Connective Tissue Structure in Human Subjects with Chronic Low Back Pain,” BMC Musculoskeletal Disorders 151 (2009): published online. doi:10.1186/1471-2474-10-151.121
Helene M. Langevin et al, “Reduced Thoracolumbar Fascia Shear Strain in Human Chronic Low Back Pain,” BMC Musculoskeletal Disorders 203 (2011): published online. doi:10.1186/1471-2474-12-203.122