Thanks to several high profile news articles and news reports a heightened awareness of opioid pill mills and the doctors that run them came into the awareness of not only the American people, but various government agencies, as well. This was not such a bad thing, but what was never addressed by the news articles (many covered in the Los Angeles Times) were the thousands of patients living with chronic pain that were finding benefit from opioids and the conscientious doctors that made a point to monitor their patients for compliance.
The constant focus on those who die from opioid abuse and the doctors that prescribe opioids willy-nilly overlooks the reality that many more people have benefited from opioid use and do so without abusing the medication. The 2012 LA Times series on opioid abuse and deaths has been referenced in nearly all opioid cautionary articles since the series first ran with the factoid that between 2006 and 2011 there were 3,733 opioid-related deaths in four Southern California counties (Los Angeles, Orange, San Diego and Ventura). Though 3,733 is a staggering number of opioid-related deaths, the LA Times reporter failed to provide perspective; such as, during this same period of time there was a total population of 16.9 million people (as of June 2011) in the abovementioned counties and these opioid-related deaths though tragic represents .0002% of the population – my question then how does this make a raging epidemic?
Also missing in many of the reports of opioid abuse is how many individuals were not only addicted to opioids but to other drugs (both legal and illicit), and alcohol. Little effort was done on the part of the experts and reporters alike to deduce which came first the opioid abuse or the alcohol/illicit drug use. Actually in the LA Times series, it was noted that in many of the deaths that were reported as being opioid-related could only be assumed, since at the time of death the death wasn’t identified as an opioid-related death.
While the LA Times did a relatively good job at highlighting deaths related to opioid-abuse they did a disservice by not providing context and by failing to present stories from those living with chronic pain for which opioid use is the only treatment. Instead as a response to the LA Times and other similar articles various agencies and regulatory bodies began to discuss ways to “curb” the opioid epidemic. Meanwhile, few if anyone was talking about what could be done to provide support to those living with chronic pain for which opioid treatment was the only option or one very important part of their therapy to alleviate the constant, chronic pain– because that would be too easy! While the LA Times targeted California for its pill mill and opioid-related deaths (remember 3,733 people died), they failed to mention that California had the lowest person to opioid rate of all 50 states. They failed to address how insurance, in particular Workers’ Compensation, seemed reticent to provide alternative treatment for people living with chronic pain. For example, Workers’ Compensation puts a cap on the number of physical therapy (PT) sessions an injured worker can have, in total, over the course of an injury. This doesn’t mean that a Workers’ Compensation adjuster can’t approve more (PT), but far too many adhere to the strict guideline; even if PT is the recommended course of treatment for recovery from a particular procedure, so all too often doctors have to rely on opioid treatment in lieu of PT.
While it may seem as though states regulatory agencies have done little to curb opioid abuse a map/document produced by Progressive Medical outlined with some thoroughness state opioid rules by restriction, and though this document was published in 2013 it provides a good snapshot of these restrictions by state and can be found here – OpioidRulesByRestriction + MAP_10-15-13_FINAL.
So with so many people and agencies focused on the “problem of opioid-abuse” no one seems willing to advocate and address the needs of people living with chronic pain for which opioid treatment is the only option. There’ve been a few groups that have spoken out, but their voices are often muted by the screams of those who seem intent of removing opioids completely from all formularies. Prescription Drug Monitoring Programs (PDMP) such as California’s Controlled Substance Utilization Review and Evaluation System (CURES) programs have shown little effectiveness. Meanwhile, CURES has a very low utilization by California physicians and pharmacists. Meanwhile few states, including California’s CURES updates in real-time. Oklahoma is one of the few states whose program updates with very little lag-time which allows both prescribing physicians and pharmacists to access the Oklahoma PDMP in real time which helps weed out pill shoppers and helps in the identification of possible pill mills.
Draconian measures will not solve the challenge of opioid-related deaths or abuse or those running pill mills. What’s needed is a balance and sane approach. Doctors need to be well educated on when opioid use is optimum, how to detect possible doctor shopping, non-compliance and so forth. In turn patients and their families need to be educated on appropriate opioid use and provided tools to be both compliant with treatment protocol and to be aware of possible signs of opioid dependency. For example patients who are in extreme pain may not be cognizant that they just took their Vicodin because when a patient is in a state of extreme pain they experience time differently. I should know I had to endure an Ilizarov external fixator for a time and if not for a note that I kept at my bedside where I would document each time I took the Vicodin that had been prescribed to me there would’ve been times when I could’ve sworn that two hours had already passed since my last dose. I can’t recall one occasion where physician, nurse practitioner or nurse ever recommended a method to track when medication, especially opioids, that had been taken.
On the upside conferences such as PainWeek offer caregivers, practitioners and patients alike an opportunity to learn about the various manifestations of pain and the different modalities to treat pain. I’ve truly enjoyed attending PainWeek these past two years and I am looking forward to more networking this year.