Friday, July 22, 2011

The dilemma of Pain and Addiction

I read this article in the Wall Street Journal online recently which discussed some of the issues about pain medication in America. The difficulties experiences by doctors in the USA are definitely shared by those of us here in Australia.

The challenges of dealing with people presenting with chronic pain and requesting narcotic analgesics are numerous.

Firstly, pain is subjective. There may be only a partial relationship between the actual severity of the problem (illness or injury) causing the pain and the intensity of the pain itself. A person's experience of pain is also influenced by their beliefs about what the pain stimulus means, their intrinsic ability to cope with stress/distress, learnt responses to pain from past experiences, current emotional state and other psychosocial influences. This can be particularly so in the context of chronic pain.

Secondly, even in the absence of addiction, narcotics may well be a poor treatment choice for treatment of pain. The scientific evidence for the use of narcotics in acute pain is pretty good whereas the evidence for the use of narcotics in treating chronic pain is scant and inconclusive. In many cases narcotics will have a detrimental effect on health as many people who dull their pain with narcotics then opt not to participate in the physical rehabilitation needed to improve injuries or the psychological therapies which could improve quality of life.

Thirdly, the risk of developing an addiction to a narcotic following a significant exposure is estimated at around the 10% "ball park". This means that in a significant number of people that are prescribed narcotics, the doctor will be causing an addiction... and remember "do no harm"

Fourthly, doctors are trained to help people and it can be difficult for a doctor to refuse a narcotic prescription to a patient who wants something to stop pain. We (doctors) are not well trained enough in how to say "no" when we need to.

Fifthly (I did say "numerous"), people with opiate addictions do lie about experiencing pain in order to get narcotics to feed their addictions. Often these same folk exhibit a range of inappropriate drug seeking behaviour and can be aggressive and violent towards hospital or clinic staff, "doctor shop" to multiple prescribers, engage in illegal activities such as theft or forgery.

Sixthly, there is a substantial black market for diverted opiate medications. In Australia this is particularly problematic as the national subsidy for medications (the PBS) means that folk on social security only pay just over $5 AUD for a prescription for a month's worth of medication but can sell individual tablets for up to $1/mg morphine (receiving $80 for a single 80mg tablet, where 60 tablets cost $5). This presents a real temptation to on sell their medication, resulting in more narcotics on the streets contributing to overdose risk, injecting drug use related risks. etc.

Seventhly, opiates are not completely benign medications. They represent a significant overdose risk as well as increase the risk of other health issues including sleep apnoea, falls, osteopaenia, cardiac problems (eg ST segment prolongation and heart block)...

The challenge for the health sector, not just individual doctors, is to ensure that people who legitimately need treatment are able to receive it; that people with no legitimate need do not get access to it either via prescriptions or the black market; that medications are prescribed safely and responsibly taking into account the potential risks. This involves the development of better prescription monitoring systems that provide real time reporting, and the development and widespread adoption of universal precautions in opiate prescribing in order to reduce the substantial risks that narcotics can represent (the Prescription Opioid Policy put together by the combined efforts of the colleges of physicians, anaesthetists, GPs and psychiatrists discusses this at length).

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