What's worse: the chronic pain or the medication for it?

by Dr Oleg Reznik

The facts about drug treatments for depression
A real life case
Another opinion
Bipolar Without Drugs
Psychiatric Drugs as Agents of Trauma

   With vast scientific advances came medical interventions that claim to save lives and relieve suffering. While our abilities to treat trauma and acute illness has improved dramatically, modern society is plagued by chronic illness and chronic pain, for which the best we can promise is to slow down the progression of illness.

   The expanding array of opioid pain relievers has led to unprecedented levels of addiction and injury related to their use. In addition to causing physical and psychological dependence, opioid pain relievers have numerous side effects. Examples include hyperalgesia syndrome (after some time the chronic use, the narcotic analgesics begin to actually cause more pain), sleep and psychomotor disturbances, bladder and bowel dysfunction, major cardiac rhythm abnormalities that can be deadly, and hormonal changes (for example testosterone levels can decrease by more than 50% in a male and take months to get back to normal even after stopping narcotic use).

   It is possible to taper off the opioids but this requires careful medical supervision by an experienced practitioner, particularly after long term use.

   Medical guidelines advise health professionals to give opioid pain relievers when milder medications have not worked, and to go on giving them indefinitely. These guidelines, however, are based on inherently weak research. First, there is no true placebo control with mood altering substances. Second, the studies are much shorter duration than the actual real world use of these medications. Third, research relies on self-report of patients who are given a mood altering substance. Finally, the harms cannot be adequately assessed due to the strict inclusion and exclusion criteria that have to be observed in a typical research design, which results in inability to capture the collateral harm from the use of these substances.

   This problem with data pertaining to chronic pain management has long been recognized and more recently there has been more interest in the epidemiological data which is more and more compelling. While treating acute, surgical, traumatic and end of life pain seems very appropriate, the practice of prescribing habit forming medications for years for patients with chronic non-cancer pain is not well supported by evidence.

   Health Policy Review published in 2007 indicates striking figures: the US, which constitutes about 5% of the world population, consumes 80% of world's supply of pharmaceutical opioids. Under the guise of "chronic pain management" we have legalized opioid distribution and consumption to unprecedented levels. The same report indicates a 542% increase of New Abuse of Prescription Opioids Among Teenagers from 1992 to 2003. Here methadone, oxycodone, fentanyl, hydromorphone, hydrocodone and morphine top the list.

   Unintentional drug poisoning mortality rates increased on average 5.3% per year from 1979 to 1990 and 18.1% per year from 1990 to 2002; the rapid increase during the 1990s was attributed mostly to narcotics. Between 1999 and 2002, the number of opioid analgesic poisonings on death certificates increased 91.2%, while heroin and cocaine poisonings increased 12.4% and 22.8%, respectively.

   A more recent 2010 National Survey on Drug Use and Health reports that among persons aged 12 or older in 2009-2010 who used pain relievers non-medically in the past 12 months, 55% got the drug from a friend or relative for free.

   A 2010 Morbidity and Mortality Weekly Report indicates that in 2008, US drug overdoses caused 36,450 deaths. Opioid pain relievers were involved in 14,800 deaths (73.8%) of the 20,044 prescription drug overdose deaths. Death rates varied fivefold by state and were related to the rates of prescribing of these medications. In 2009, 1.2 million emergency department (ED) visits (an increase of 98.4% since 2004) were related to misuse or abuse of pharmaceuticals, compared with 1.0 million ED visits related to use of illicit drugs such as heroin and cocaine. In 2007, nearly 100 persons per day died of drug overdoses in the United States. The death rate of 11.8 per 100,000 population in 2007 was roughly three times the rate in 1991. Prescription drugs have accounted for most of the increase in those death rates since 1999.

   A 2012 article in the Journal of Pediatrics reminds us of the thousands of children under 5 sustain significant injuries related to the prescribing of opioid pain relievers. The researchers obtained patient records from the National Poison Data System of the American Association of Poison Control Centers for children up to years from 2001 to 2008 and evaluated 453,559 children for ingestion of a single pharmaceutical product. Child self-exposure was responsible for 95% of visits. Child self-exposure to prescription products dominated the health care impact with 248,023 of the visits (55%), 41,847 admissions (76%), and 18,191 significant injuries (71%). The greatest resource use and morbidity followed self-ingestion of prescription products, particularly opioids, sedative-hypnotics (stronger sleeping pills), and cardiovascular agents.

   I could go on and on with the numbers but numbers cannot capture all the harms that are more difficult to apprehend, measure and interpret; the philosophy of relying on an external fix for problems, physical or emotional; the disruption in social and family life; the emotional, moral and spiritual trauma of an approach to life that views unpleasant experiences as random events that need to be eliminated, numbed-up or forgotten with the use of equally random "magic pills" (not related to the specific circumstances of life of an individual) that have been given to us by randomized and not well controlled clinical trials.

   While we aim to relieve suffering, our ability to do so is very limited -- a fact that must be recognized by both patients and health practitioners. In caring for the spiritually inclined person, I sometimes remind myself and the patient a verse from James 1:2 "My brethren, count it all joy when ye fall into divers temptations; Knowing this, that the trying of your faith worketh patience. But let patience have her perfect work, that ye may be perfect and entire, wanting nothing," or a verse from a 17th century monk Brother Lawrence "...the Lord sometimes permits disease of the body so that problems within the soul can be cured... Come to the Lord, ask Him not to deliver you from your pain, but ask Him for strength to bear this thing."

   Being in a position of giving advice, I need this reminder more than the patient, lest I overstep my boundaries to suggest to the patient that I have God-like abilities of removing suffering and death, which I surely don't.

Oleg is one of the contributors to my book Cancer: A personal challenge. He is a wholistic physician who keeps getting in trouble with authority for daring to think for himself, on the basis of publicly available evidence.