Opioids - Narcotics for Chronic Pain

Opioids - narcotics for chronic pain

We are hearing a lot in the news about the addiction to prescription narcotics like oxycodone and fentanyl and death from overdose…

What indeed is going on? As usual the answer is complicated. You are going to get the perspective of an experienced family doctor here. There are in my opinion 3 drivers:

First is patient demand. Consider that you are a doctor, seeing a patient every 15 minutes. One of them is a drug user just recently let out of jail. He claims he has been taking narcotic for years, has a threatening manner and refuses to accept that you won't prescribe without old records. OK, I am a 70-year old grey-bearded man and I’ve gotten all sorts of pressure from all sorts of patients before. I can say no but it’s a very uncomfortable situation. If I were smaller, or younger or female I might feel threatened and say yes just for my own safety.

In my very first month of practice I was confronted by an elderly woman who came with a shopping list of addictive drugs and threatened to commit suicide if I didn’t give them to her! True blackmail, which I treated as just that. I threw her out of the office and spent that night wondering what the headlines in the paper would be, even though I understood that she was just going to keep on making that threat until some doctor gave in.

Then there are the patients who threaten the doctor with a bad review if s/he doesn’t accede to the demand for drugs. This is happening a lot in the US where the business model of medicine makes patient satisfaction more important than good medicine. But these things cross the border and patient satisfaction is one of the mandated measures of the success of family health teams, putting the same pressure on Ontario docs.

The second drivers are professional guidelines and scholarly articles suggesting doctors don't treat pain adequately. I have become a real skeptic of "consensus guidelines". Too many guidelines are written with too many writers paid directly or indirectly by the pharmaceutical industry for me to follow them blindly. Drug companies have one real purpose, to sell drugs. It is invidious.

Driver three is doctors. Some doctors find it easier to give a narcotic than to explain a better course of action. There is just no good reason why a patient should leave the emergency department of a teaching hospital with a prescription for oxycodone for a sprained ankle. I've seen physician laziness with patients who are on narcotics after surgery. They go to a convalescent facility where the new attending physician just continues to prescribe them for the whole rehabilitation period because, as one said to me, "it's too much trouble to take them off; I'll let the family doctor deal with it later." We docs are not blameless.

When are narcotics useful? Pre-operative pain - I am a patient in the emergency room with a twisted bowel, yes please give me morphine. Post operative pain - I've had major surgery, for just about anything, yes please I'll take the narcotics. Cancer pain, please, give me whatever it takes to keep me comfortable.

I use narcotics for severe pain where other medications can’t be given, for example a young man with terribly painful kidney stones, who had already kicked a narcotic habit once and whose kidneys were in such bad shape he could not tolerate the usual medications.

When are narcotics not useful?

Minor pain or injury; no excuse and that includes 99.9% of back pain. Chronic non-cancer pain; this is where the problem actually lies. A recent review article in the best medical journal stated clearly that there has NEVER been a properly designed clinical trial showing benefit in this group of patients, period. I have only rarely seen a patient on long term narcotics who was not harmed by them.

Now imagine that you have had a pain in the mid back for 29 years with no good diagnosis and no effective treatment. Imagine too that you can't stand long enough to fry an egg, and it even stops you from having sex. I don't know about you, but I might be anxious, depressed, angry, hopeless, and distrustful of doctors.

Well, the body is not stupid. There MUST be a reason for the symptom to be present. My job is twofold. One is to find the anatomical origin of the pain. The other is to alleviate the pain. And these two things can be in conflict. Imagine that you are fighting a forest fire. The goal is to put out the flames and limit the damage. You don't go looking for the match that started it. AFTER the fire is out, you can talk about fire safety and prevention, but during the inferno, the objective is to douse the flames.

So it goes with people. Sometimes, after calming the fire, I am able to uncover a lesion that I can fix... a tendon strain or make a diagnosis of a pinched nerve. And when I can do that, I can do some magic - inject a tendon or bursa, or provide a coherent explanation of what is going on and what to expect. But these are the unusual cases. Most of the chronic pain patients I have seen fall into the forest fire category. A specific diagnosis is impossible.

What do I tell these people? First is to reassure them that they are not crazy, that long term pain without a good diagnosis or relief leads to depression and anxiety, and depression and anxiety magnify the pain - a true vicious circle.

And then I am clear that long term narcotics are not the answer. So for those who are on them already hooked and interested, we begin a slow program of narcotic withdrawal, replacement with non addictive drugs, and psychological treatment. For some it is impossible and I am comfortable with giving them a stable dose but never escalating it. For some it takes a long time until there is enough trust built up so that I can start a withdrawal program or get them interested in an addiction clinic.

One of my success stories was a soldier who became hooked on narcotics after an injury. As is always the case he was very afraid of pain and withdrawal symptoms. But he was motivated, and I agreed to work with him. It took 2 years, with many ups and downs, but he did it. I got a thank you card for saving his life hand delivered a few weeks after he was clean. It was one of the hardest jobs I ever did as a doctor and one of the most rewarding.