It turns out that Twitter is an inadequate forum for discussing the issue. Twitter is an ideal format for discovering if a poster knows anything at all about the problem. A lot of people don't and they seem to just be there to argue. I don't have a lot of time to waste on political approaches to medicine. Political approaches to medicine typified by managed care companies, pharmaceutical benefit managers, and government guidelines that are supposed to improve care but don't are the reasons we have an expensive, fragmented and inefficient health care system.
The apparent political factions on Twitter consist of pain specialists who take the position that pain care and access to opioids is now being rationed and their pain patients are being unjustly treated. They claim there is a faction of addiction specialists making various claims that they take offense to. But my experience there is the past few days is that these are all basically red herring arguments. A few of those claims include the idea that addiction specialists would consider pain patients "drug seekers", would recommend treating pain with only acetaminophen, are calling pain specialists "quacks", and of course that addiction specialists have some interest in distorting and overplaying the dangers of opioids. In some cases the arguments have gotten to the absurd claim that the pain advocates (or more appropriately anti-addiction contingent) claims that most heroin users start using heroin directly rather than using legitimately prescribed or diverted pain medications first.
Where is the reality in all of this distortion? The reality centers like most things in medicine in primary care settings. The hundreds of thousands of internists and family physicians who provide the bulk of care for almost all problems in the US. As I have posted on this blog many times, the evidence from both the CDC and CMS is that the majority of these physicians do a good job with opioids. Only a fraction of their number prescribes a disproportionate amount of opioids. Many of these physicians have a bias to underprescribing if anything. That means the bulk of physician punitive legislation about mandatory course for opioid prescribing for these physicians will be just that - punitive toward most physicians who already know about prescribing these medications. That legislation is also untested in terms of whether it will have any impact on the physicians who are overprescribers.
The other facet of the problem is overprescribing in general. Part of the quality problem in medicine today is that the business and governmental management systems are focused on a brief physician-patient encounter where some medication gets prescribed. That is the focus of the encounter. Patients expect that and come in the door with a medication request. That results in predictable overprescriptions of medications from many classes. The classes that reinforce their own use - opioids, stimulants, and benzodiazepines are more problematic than the rest.
At the extremes of this landscape are the pain specialists on one end and addiction specialists on the other. Both have a broad spectrum of quality settings from state of the art to nonexistent. These specialists know this and they know there is very little that can be done about it except to mind your own business and do the best job possible. There are pain clinics that are "pill mills" where there is an understanding that a cash exchange with a prescriber will get you a script that can be filled on site for opioids. That prescription is then sold in the parking lot for diversion. There are other pain clinics where no attention is paid to addiction, psychiatric comorbidity, polypharmacy or the functional capacity of the patient being treated. There are similarly low quality addiction treatment facilities where people are warehoused with no active treatment. Where there is no therapeutic environment because nobody in the program is willing to consider that they may have an addiction. There are programs where there is no medical supervised detoxification. There are programs where there is no medication assisted treatment for opioids or alcohol use. There are programs that do not address psychiatric comorbidity. There are programs based on some sketchy ideas that have no proven relevance in treating addictions. The houses of both pain and addiction specialists are not perfect because of these serious flaws. And let's face it - the regulators of every state in the union are to blame for having so many low quality pain and addiction treatment facilities open for business and accepting reimbursement for shoddy services.
For a moment - let's return to the idealistic world of the Twitter protagonist where the position seems to be "I am all knowing and do a perfect job." The realities will differ based on whether you are on the addiction or pain specialist end of the spectrum. To illustrate, I am on the addiction end and 100% of the people are see have addictions or substance use problems. On any given day the problematic substances average out to about 30% alcohol, 30% opioids, 20% mixed, 15% stimulants, and 5% cannabis. Of the opioid users 30-50% have chronic pain problems. In every case, I have a detailed discussion with the patient about how their substance use problem evolved and what keeps it going. Over the years I see thousands of people with these problems and in that process come to know a lot about the associated issues. My opinion is not based on my personal experience or politics. My opinion is based on understanding the problems of thousands of people that I am supposed to help. For example, when somebody tells me that the "average" heroin user in this country starts using heroin rather than prescription painkillers - I can say that is unequivocally wrong. I have heard all of the details about how heroin use begins and it is almost always with a prescribed or diverted pain medication. When somebody tells me that taking a person who is addicted to opioids and who has chronic pain off of opioids is cruel - I can also say that they are wrong. I have had those same people tell me that they have never felt better and in less pain in years. I can also say the following based both on research, theory and clinical experience:
1. A significant portion of the population is predisposed to addiction -
My estimate would be about 40%. When a genetically predisposed person uses an intoxicant their reaction to it is markedly different from a person who lacks that predisposition. Opioid users report an energetic hypomanic felling where they have mental clarity like they have never experience before. In some cases they will say that they felt like they had become the person they always thought that they could be. This is a highly reinforcing state that leads to more opioid use.
2. If the population predisposed to addiction is significant - the only limiting factor is access or availability -
This is the basic reality of the current opioid epidemic and of course very drug epidemic (methamphetamine, cocaine) that the US has seen over the past 200 years. It is quite easy to look down from the high perch of a low availability area with low addiction rates to a high availability area with high addiction rates and conclude that "there is something wrong with those people". The usual conclusion has been that they are morally defective. This is how addiction services have been rationed, poorly researched, and fragmented over the years. Even if you subscribe to a top health plan in the country - it is likely that you will have poor access to quality addiction care because of these attitudes.
3. The burden of prescribing medications that reinforce their own use falls squarely on the prescriber -
It is above all else an informed consent issue. The patient needs to know that the medication they are taking is not a panacea and that there are significant risks up to and including addiction and death. They also need to know that these medications can have cognitive side effects and affect their day-to-day functioning. They should not be prescribed solely out of the notion that the physician feels like they need to do something for the patient. There needs to be a pain diagnosis and treatment plan. In the case of chronic pain the patient needs to know that there is no known medication that completely alleviates chronic pain and therefore continued dose escalation of opioids is not a solution. The treatment plan needs to contain more elements than taking the opioid prescription.
An associated prescriber issue is polypharmacy. Chronic pain is frequently associated with anxiety, depression, and insomnia. That can lead to a contraindicated polypharmacy environment that includes a benzodiazepine, a z-drug, or a sedating antidepressant used with the opioid. It can also lead to the patient taking alcohol or diverted sedatives on their own initiative with the opioid.
4. Chronic pain patients taking opioids need thorough evaluations if possible -
Some people in the Twitter debate seemed shocked by the idea that opioids are taken for reasons other than pain relief. I suppose they would be even more shocked if they heard that there are people that take them who get no pain relief at all from them. They taken them strictly because of the positive euphorigenic effects. There are also people who take them despite the side effects for the same reason. The first thing a physician needs to do is step back from the indication - prescription mode that most American physicians have been trained in to take a look at the entire prescribing landscape.
That means that is a person has come to idealize a medication or abusable substance they will start to use it for anything - insomnia, anxiety, depression, or "just to feel right to get through the day." As many people tell me: "Look doc - if you can't get rid of this depression I know what I can take to feel OK for a couple of hours." On Twitter and some other blogs readers are incensed that these behaviors exist and yet they are documented in the literature (see paragraph 6).
When I say if possible I am more aware of the fact that patients lie to physicians than non-addiction specialists. I have had an endless number of patients tell me that they can get whatever addictive medication they want out of one physician or another. The Mayo clinic had an addiction medicine conference three years ago and one of the presenters was a patient in recovery who basically talked about how he systematically lied to physicians to get opioids for years. He talked about how he could identify a physician who would give him the script that he wanted and who would not. In the case of the latter he would just move on to another clinic.
Many non-addiction specialists consider it to be poor form to suggest that patients lie. That denies the basic reality that everybody lies. It also denies the reality of addiction, that you are transformed into a person who is dishonest and a person that you never thought that you would become. In the addiction field it is critical to acknowledge this to help people deal with guilt and shame so that they can recover. The worst thing that can happen is to collude with dishonesty when the final result is the prescription of an addictive drug. I do not consider it to be an issue that I can get this history when the physicians being approached for the medication cannot. It is all part of the illness of addiction. On the other hand, if you are the opioid prescribing physician - the amount of information that you can get asking the direct questions about problematic use is not known until you try it.
All things considered it is possible to treat people with chronic non-cancer pain with opioids. I have been involved in that treatment before I switched to seeing only patients with addictions. I consulted with some of the top pain experts in the state. All the limits in this post need to be acknowledged and cautiously addressed. The treatment of chronic pain is not perfect, I know that because I see a lot of the failures. Addiction treatment is not perfect either. The treatment needs to be highly individualized.
I wish that I could provide more clear guidance to the patients involved. As an individual I cannot just start pointing fingers at the places (pain clinics and addiction treatment) that I think should be shut down. I think that you need to depend a lot on your primary care physician referring you to places that he or she knows will do good work. On either the addiction or pain end of the spectrum - there has to be more going on than the prescription of medications.
Even the most basic psychological models suggest that other cognitive, emotional, affiliative, spiritual and reconditioning changes need to occur.
George Dawson, MD, DFAPA
