As a nurse practitioner in a busy suburban emergency department, pain is my job. Pain is one of the most common reasons people come to an emergency department (ED). It could be abdominal pain, chest pain, back pain or even emotional pain, including depression or suicidal ideations. Pain is a driver for people seeking medical care. We have made pain into a vital sign, and we ask, “How would you rate your pain on a scale of 1 to 10?” a mandatory question for any patient who steps through our door.
This whole concept evolved circa 1987 when the Institute of Medicine urged healthcare providers to use a quantified measure for pain. It gained even more traction in 1990 when then president of the American Pain Society, Dr. Mitchell Max, called for improved means to assess and treat pain. The term “oligoanalgesia” gained popularity in the published literature, meaning that we weren’t giving enough pain medication to patients in the ED, in clinics or in any other healthcare setting. Healthcare providers responded. We asked about and we thought, more effectively treated pain to address this issue.
Pharmaceutical companies paid attention to this too. One of the best examples is Purdue Pharmaceuticals who heavily marketed its product Oxycontin. They made claims, which ultimately were fabricated, that Oxycontin was a safer, less addictive alternative to any other opioid on the market. The response was that millions of tablets of Oxycontin flooded the market, netting Purdue nearly $31 billion in profits.
Overprescribing has been blamed, at least in part, for our modern opioid epidemic. In 2016, there were 240 million opioid prescriptions prescribed annually in the United States, enough for one prescription for every adult. To help curb this, the CDC published opioid prescribing guidelines, states enacted policy including prescription monitoring programs and prescribing limits and providers started to self-police prescribing habits. This did lead to an overall decrease in the number of opioid prescriptions, with 55 million fewer opioid prescriptions in 2017.
These efforts have reduced the number of opioid prescriptions. What hasn’t changed however, are the number of opioid related deaths. If anything, there is some data that demonstrates these limits have increased opioid related deaths. Similarly, there has been a shift from the historic entry into opioids being prescription opioids, to the more dangerous and often lethal illicit drugs like fentanyl.
Why is this happening?
Cutting the supply chain should result in fewer people having access to opioids, with downstream decreases in non-fatal and fatal overdoses. But its not, and here is why. What hasn’t been addressed is what is happening to people who are in pain. The root of the opioid epidemic is after all, all about pain. It is about emotional pain from anxiety, depression and trauma. It is about isolation, disrupted families, housing instability, marginalization and stigma. It is about physical pain, both acute and chronic. We have taken out one piece of the puzzle, the drug, but we haven’t replaced it with anything else. Its akin to taking away insulin or statins. Eventually, the disease is going to catch up to you.
As we have with many of our attempts to address the opioid epidemic, we are making really broad strokes to combat a rather heterogenous issue. In trying to kill the weed, we are cutting of leaves, without ever really just digging in and pulling out the roots. Efforts to curb prescribing are noble as are harm reduction and increasing access to mental health. We must however address the issue of pain if we are to make any progress in this epidemic.
Construction workers are seven times more likely to die from an opioid overdose compared to other professions. Fishers are five times more likely. These are both demanding, physical jobs. They have long hours, they are physically demanding, and they are often sporadic and transient. Rates of depression are almost two-fold among workers in the fishing industry, owing to the demands of the job, the isolation and job insecurity. This is coupled with lack of access to healthcare, insurance and mental health resources. For those with substance use disorder, current regulation around methadone and buprenorphine/naloxone make access to these life-saving medications difficult, if not impossible.
There is a fine line between under-, over- and appropriate opioid prescribing. Health disparities, poverty and stigma all contribute to this public health crisis. The word crisis however often elicits a knee jerk, band-aid reaction to problems. This is a complex, multi-faceted problem that isn’t going to be fixed with a roll of duct-tape. There is a real need to address pain, both physical and mental, in order to get to the root of this issue. This may include better prescribing habits, closely monitored low-dose opioids for some individuals, as well as increased access to alternative treatments like acupuncture and massage. Providers and patients alike need to have frank conversations about the process of pain, expectations and outcomes. Increasing access to healthcare for underserved populations may help to diagnose and treat painful conditions earlier in their course.
The pain is real.
Be it PTSD, crippling anxiety, severe depression or painful conditions like overuse injury, disc disease or arthritis, the pain is why people turn to opioids. There is no doubt, self-medication with any drug, from opioids to alcohol can be detrimental if not devastating. The healthcare profession and policy makers however, can’t just pull the plug and leave people stranded. There needs to be a national conversation on addressing pain so that we have a more thoughtful and comprehensive approach to this epidemic.