especially high dose narcotics, seems to be an academic argument given the
widespread availability of these medications prescribed by family physicians, surgeons,
and pain physicians, there are many other thorny issues affecting availability. Lets
look at these one by one:
1. Question: Isn't it a patient's right to be treated until they are out of pain?
Answer: No one has the right to narcotic pain treatment under any circumstance.
The most stringent guidelines used by JCAHO accredited hospitals require only that
physicians treating patients in these hospitals will assess the pain and treat pain.
Period. There is no right to narcotic treatment, even if all other treatments are
ineffective. It is an ethical duty of doctors to attempt to relieve pain, especially by
physicians who advertise themselves as "pain management" physicians or specialists or
"pain medicine physicians". However, there is no legal requirement for physicians to
use narcotics to treat pain.
2. Question: Why are doctors so reluctant to treat with narcotics when so many
studies have shown an almost non-existent addiction rate?
Answer: Because the studies are wrong. The most commonly quoted study
demonstrating 0.04% addiction rate was performed on acute care hospitalized patients
who were asked after discharge if they were addicted to narcotics. It is well
documented acute pain and chronic pain are virtually unrelated except for the word
"pain" appearing in both terms. Acute pain patients rarely become addicted to
narcotic pain medications as a treatment for acute pain in a hospitalized controlled
setting. Comparisons with the chronic pain population in an ambulatory uncontrolled
environment are ludicrous. Manufacturers of narcotics attempting to increase sales of
their products intentionally misquoted and mislead physicians and patients alike by
using such nonsensical comparisons between acute and chronic pain. Furthermore,
other studies demonstrating a low addiction rate in a tightly controlled population
excluded those with addictive tendencies, thereby appearing to shift the safety profile
of the drugs to a point higher than even the general population. The addiction rate to
all drugs excluding alcohol and cigarettes, is approximately 7% and that of pain killers
is approximately 3% based on US government household annual surveys. Several
studies which are well conducted did not simply ask patients if they "felt addicted" to
pain medications, but attempted to monitor their behavior by querying all local
pharmacies and other physicians about a specific patient's narcotic use. These studies
demonstrated a 25% substance abuse rate which other studies using random drug
screens found up to 50% of populations attending chronic pain treatment centers to be
substance abusers. So in conclusion it is certainly not possible for the chronic pain
population to have a less addiction rate to potent narcotics than the general population,
and in fact, chronic pain patients have been shown to have several times the general
population's rate of substance abuse. That is why many physicians do not prescribe
opiates for chronic pain. Additionally, a population of substance abusers requires an
enormous amount of the clinic staff and physician time receiving calls about how the
patients lost their medications, had them eaten by the dog, lost their prescription, have
no idea what happened to them even though they were not kept in locked quarters, and
are often hostile, threatening, and overtly irresponsible. Tight controls on the
prescribing of narcotics with pre-defined responsibilities of patients and with no
exceptions made is the only way physicians can safely prescribe narcotics to patients
for chronic pain.
3. Question: But narcotics help me survive and live day to day. I have heard pain
patients have a 9 times higher suicide rate than non-pain patients. Isn't it the place of a
doctor to have compassion for his patients?
Answer: This statistic is a widely quoted and undocumented urban legend. The fact
is that as the population ages, even though the incidence of chronic pain continues to
increase, the suicide rate actually drops significantly. Other studies have shown pain
patients taking narcotics who are contemplating suicide actually take less pain
medications than prescribed 44% of the time. If pain were the primary reason for
suicide, then all pain patients who are suicidal would take more narcotic medications
than prescribed. The primary reason for suicide is depression, not pain. Because there
are significant numbers of depressed patients in psychiatric units who claim to have
pain while there are also large numbers of pain patients demonstrating signs of clinical
depression, it is not possible to incisively separate the two groups. However, it may be
concluded that if there is an increase in pain patient suicides, it is at most a small
increase compared to the general population or clinically depressed populations suicide
rates.
4. Question: Well since narcotics are safe other than addiction, why not just
psychologically screen each patient and give patients the amount of narcotics they
need for chronic pain?
Answer: There are many conditions in which narcotics may be overtly dangerous or
are contraindicated altogether. For instance if a patient is sleepy, groggy, cannot think
straight and attempts to drive or use machinery, they may injure or kill themselves or
others. Other side effects include a rapidly increased side effect profile of sedation
and respiratory depression in those with changing kidney or liver functions, often not
even recognized by the patient. Many pain patients have set their houses on fire
through smoking while so groggy due to narcotics that they cannot stay awake long
enought to put out the cigarette. Sleep apnea or severe chronic obstructive lung
diseases may make the use of narcotics extremely dangerous. A thrill seeking
personality, use of illicit drugs, past history of any substance abuse at all including
cigarette smoking, places a person at higher risk of abuse of the prescribed narcotic.
And sadly, not all patients are legitimate pain patients. Some fake their way into
receiving narcotics, often from several doctors in a week, and may sell the drugs or
trade them for illegal drugs. Since there is no pain meter, and many pathologies do not
show up on xrays or MRI, it is not always possible to tell fake patients from real
patients. That is why tight monitoring of the use of the narcotics is so very important.
Rapid dose escalations without the physicians expressed consent is one of the most
evident problems seen in substance abusers.
5. Question: I have been on the same narcotic drugs for years and they work as long
as I don't do any activity. Why does the pain doctor insist on my increasing activity,
doing blocks, engaging in physical therapy, and use of other methods when the
narcotics work so well?
Answer: One of the main goals of pain management is to restore some function.
Laying around, becoming obese because of unaltered eating habits, smoking cigarettes
which continue to destroy the discs in the spine, and becoming a vegetable content on
surviving watching television is entirely unacceptable to pain management. If that is
the goal of patients, they would be better off seeking their narcotics off the street and
will often be (and should be) discharged from the pain practice. Narcotics certainly
have a role in pain management but are entirely inappropriate when used as the sole
method of pain control without improvement in function. Exercise, even home
exercise daily, is absolutely mandatory. There is no way to increase function without
the motivation to exercise and strengthen muscles and improve flexibility. These
measures alone have been shown to be far more effective in the long term than are
narcotics. Therefore most competent pain management physicians will constantly
push patients into methods of functional restoration which may include, but should not
be limited to physical exercise or injection therapies.
