Recent articles have suggested that we are perhaps overreacting to the increased use and/or abuse of pain medication, and we are perhaps still under-treating pain, while stigmatizing and confusing doctors, and panicking needlessly. So we try to look at the bigger issues of what is pain, why does it persist, and even if abuse numbers are low, what are the implications for the addiction-sensitive population.
Transcript (edited):
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, I am Howard La Mere. A whole raft of interesting articles have shown up recently. NPR is doing a series on depression, highlighting the expanded, experimental use of Ketamine as a quick acting antidepressant. Also some stories about changes in gambling laws and how that could be an issue for people addicted to gambling and also a story on Ritalin questioning whether it is as effective in addressing ADD, especially in children as we believed. So, Darryl, which of those sounds most interesting to talk about?
DARRYL: There is a lot of meat to look at today in the news and every one of those are of interest to me. They present some new wrinkles, I think, in the age- old problem of using medications for legitimate purposes, and concerns about diversion and abuse. So, let’s start with the piece from the Huffington Post and the Wall Street Journal, calling overdone reports on prescription drug abuse and prescription drug death a panic reaction, especially the opioids, stating that very few iatrogenic addictions ever occur, which is actually true and that very few patients who are treated for chronic pain ever abuse these drugs, which is also true. But these articles discount the addictive process. They discount those who will develop an addiction to chronic pain medications, the opioids and specifically how devastating that is even though it might be a very small minority of the patients being treated. These stories document sort of a witch-hunt – disparaging doctors that might have been tricked into mis-prescribing to a few drug seeking patients. Also, how the reaction is causing doctors to view anybody who asks for chronic pain medication or who is on these drugs as an addict and withholding sufficient treatment or care. So, this is a pendulum that has been swinging back and forth. Weve talked about it several times, Howard, that for awhile our society believes that pain is not being correctly treated – and this is the way the pendulum seems to be swinging according to these articles. They suggest that we should be more liberal with pain killers, we shouldnt be so worried about addiction, we should certainly prosecute those who are abusing and misusing pain killers as well as the doctors who are prescribing for profit alone, but the vast majority of people arent doing this so we should really get off of this track. And then, the pendulum falls the other way where were over prescribing, we don’t scrutinizing patients well enough, were not watching what is going on, and then mass diversion of these very addictive medications make their way into the drug abusing sub class, causing death and devastation around the country. So, its that pendulum swinging back and forth that interests me and what drives that pendulum. I think, one of the things we cant overlook is that pendulum often swings toward under prescribing when new higher potency opioids are introduced by pharmaceutical companies ….we were much more careful about scrutinizing them before. New medications like Zohydro, which is under evaluation contains 10 times the amount of hydrocodone that is currently in a Vicodin tablet… and more importantly, excludes the acetaminophens, so theres no Tylenol which means there is less chance of liver damage if somebody abuses the medication. This comes on the cusp of some studies that were published saying that high dose treatment .high dose opioid treatment of chronic pain is actually more effective than trying to control pain using lower doses. One study indicates that if a person is given a short or immediate treatment with high dose opioid medication for any pain for any kind of injury or anything, it seems to result in less chronic pain for the patient. It is estimated that anywhere from 75 million people – one story in the New York Times puts that number at 116 million or about 1/3 of this country – have moderate to chronic pain that require treatment on a regular basis. So, this is a huge population. This is a population treated with Oxycontin with oxycodone in much higher doses than Percodan contains. This medication was allegedly diversion resistant and tamper resistant but was immediately abusable on the street. I dont think Zohydro is claiming to be tamper resistant, it is being positioned as a more efficient treatment for people with chronic pain.
HOWARD: But is it a treatment at all really, or is it simply symptomatic relief?
DARRYL: Well, thats one of the big problems with pain. Pain is really a symptom.
HOWARD: Right so, if you only treat it by dealing with the symptoms, then what about the underlying cause whatever it might be?
DARRYL: Well, thats the problem with chronic pain … long after the etiology of the pain stimulus is healed or cured, people continue to suffer chronic pain and we are not sure why.
HOWARD: Is it because it becomes habituated in the body somehow?
DARRYL: It could be that sometimes people are more sensitive. It might be genetic. We really dont know but what we do know is that there is no susceptive and non no susceptive pain meaning that there is a nervous system source of pain that is not related to cell damage in the body, but rather from the brains activity. With that type a person can have chronic pain. An example is fibromyalgia, which did not exist 30 years ago and now seems to be one of the most widely diagnosed conditions. The source of the chronic pain can’t be fixed so people need to be treated with pain medications for a very long time.
HOWARD: Things that didn’t exist 30 years ago – I might be inclined to think that might be an environmental issue. Somehow something has happened in the environment to cause this condition or … it could simply be that people have had it and now it has a name.
DARRYL: There is a social reaction to pain too. A lot of people think that everyday pain is a part of life that we must live stoically with some kinds of pain and certain societies are more sensitive to that, or more accepting of that and other societies are not. Those who are not, seek treatments. On the other side of this issue – the addiction side, Ive had clients tell me about local dealers – street dealers who have a garage full of prescription vials containing Oxycontin, Vicodin and methadone. They are just able to get it. They command a good price for it, and they always have it around. You can get it. These people are diverting they are somehow able to con doctors although most people claim that they get the drugs from patients or from family members. They dont actually get them “from the garage ”
HOWARD: A garage full is not an insignificant amount.
DARRYL: The client actually testified before the state He spoke to the Southern Oregon Prescription task force about how a person can go to a known dealer and he has anything you want in his garage – tons of it.
Not everyone is going to become an addict and according to most reports, only 1% of patients treated for pain become addicted to the opioid medication (who werent already addicted) and about 3.6% of people who are in recovery for opioid addiction will have a relapse and continue use. I think that number is low. I think relapse is high. But its such a fearful thing. I had a client who developed a severe optic nerve problem. The pain was creating such a great problem that the ophthalmologist tried to kill the nerve. They tried several things. My client was an opioid addict and had been over 30 years in recovery. And he feared taking any kind of opioid medication to treat the pain, but finally the ophthalmologist said, look we cant seem to control your pain any other way and its so debilitating that youre going to have to take some opioid pain medication or were going to have to remove your eye. And amazingly it still amazes me, he told the ophthalmologist to take his eye. he gave up his eye because he did not want to have another addiction relapse and he knew if he took a Vicodin or an Oxycontin for the pain, very quickly he wouldnt be taking it for the pain. He would endure the pain so that he could stockpile enough of the drug so that he could have a good buzz every once in awhile.
HOWARD: Whats the percentage again? …. of people that get addicted..
DARRYL: Only 1% is considered iatrogenic addiction, only 1% develop some sort of addiction due to the fact that they were treated with opioids.
HOWARD: So this brings up another subject weve talked about and that has been in the news lately and its related to the Portugal experiment now being advocated by Sir Richard Branson in the UK. He is the founder of Virgin Airlines among other things and recently the governor of New Jersey, Governor Christie is advocating the same thing. He believes the war on drugs has failed and we should do essentially what the Portugal experiment did which is essentially to legalize drugs and tax them, regulate them and provide treatment.
DARRYL: Yes, that was my colleague, Dr. John Newmeyer’s mantra – we should legalize, we should tax and then we should discourage use. And I think that makes sense. If we do what Portugal did – not legalizing, but decriminalizing the use of marijuana and opioids and other drugs and saying that anybody who is caught in possession – because that is still legal and thats important to point out. Anyone caught in possession of an illicit or illegal substance is immediately evaluated. There are 3 people in every county or district who evaluate people and they are funded with the money they save on the costs of prosecution and other criminal costs. These 3 person panels assess people – if the person is a recreational user, they are fined and taxed for using the drug recreationally. If they are found to have an abuse or addiction problem, then they are sentenced to treatment. More money is being put into treatment. That makes sense to me. Unfortunately, in our country in the state of Washington and other states, there is more activity towards legalizing and taxing marijuana. The war on drugs has failed miserably because we keep investing on the supply side of that equation rather than investing in the demand side of treatment and prevention, which I think has much greater promise. If we switch the funding around our legislators and our governors and our politicians must insure that the money that is saved or gained from taxes is put towards discouraging use, towards prevention and treatment. States may be looking for another economic windfall, I predict that this initiative in the United States will fail and it wont have the impact the good impact that the Portugal law is having.
HOWARD: There was another editorial having to do with, addiction and crime – the violence in Mexico in particular, caused by the ongoing appetite in America for drugs. Because its illegal, the price is artificially increased that creates an opportunity to chase the money for gangs and cartels and criminals.
DARRYL: The advocates for legalization believe this will totally eliminate the profiteering by the illegal traffickers of drugs – which is what happened when prohibition ended. The trafficking of illegal alcohol stopped because there was no economic incentive. People forget, however, about the liquor industry – which is now legitimate, and making billions of dollars.
HOWARD: Well, it appears that this topic of drug use and abuse, legalization, decriminalization, is becoming a bit of a hot potato political issue, so I think were going to hear a lot about it in the future.
DARRYL: Absolutely. The problem with politicians is that they have a knee jerk response. They want to throw a fix in or get their share of the pie but dont have a long term view of the problem.
Chronic pain and the use of high dose opioids is a real tough one. We dont really have a good understanding of how biological systems work in terms of pain or even how medications work. In our treatment I’ve seen some people whose body quickly metabolizes methadone or Vicodin and they end up getting what would be lethal amounts of the drug every day to deal with their pain or their addiction. Of course, their doctor will be scrutinized and labeled as a “script doctor” . Tests on these patients show that they have unusual ways of dealing with the opioids in their body that most people dont have and they are valid candidates for a high dose. On the other side of that, there are addicts who might have a deformed leg and although its not causing them pain, all they have to do is show it to a physician to get pain medications and then sell it on the street. So, that goes on too.
HOWARD: There are a lot of hot button issues now and because it is very political year, were going to hear more about them. Thats all the time we have today – thanks Darryl and thanks to our listeners. We welcome your comments, questions, and suggestions, drop us an email at info@cnsproductions.com