The overuse of narcotic medications has become a national problem. Current estimates are that over 2 million Americans either abuse or are dependent on prescription opiates. Recent data reveals that15,000 Americans die as a result of an overdose or narcotic pain medications every year. More Americans die from prescription narcotic overdose each year than die from being shot. It is a national crisis.
In response to the crisis the Center for Disease Control (CDC) has issued new guidelines to aid physicians in the appropriate use of narcotic medications in the treatment of chronic pain. The guidelines are desperately needed, as chronic pain is incredibly common. 43% of American adults have been diagnosed with a chronic musculoskeletal condition and over 11% of American adults have pain every single day of their lives. In this context it is not surprising that in 2012 physicians wrote over 259 million prescriptions for pain medications.
The CDC guidelines set definitive limits on acceptable daily doses of these drugs. The limits were set based on evidence that higher doses dramatically increase the risk of overdose without evidence of significant improvement in pain or function. The maximum recommended total daily doses are the equivalent of 50 mg of morphine in most circumstances (which is approximately10 Vicodin pills, or 5 Norco), and 90 mg of daily morphine for the rare case when higher doses are indicated. The consensus is that the higher doses should typically be prescribed by pain management specialists.
Based on these guidelines I was understandably concerned by a patient I saw a few months ago in the office. His daily pain regimen included the maximum dose of an addictive muscle relaxant along with regular doses of oxycodone and methadone. After reviewing narcotic conversion charts I calculated his daily narcotic dose to be the equivalent of over 500 mg of morphine a day, 10 times the recommended daily dose. Remarkably, he was alert and seemingly unimpaired. Sadly, he was also still in severe pain.
I knew from personal research and discussions with pain specialists that he was likely suffering from “opioid induced hyperalgesia” a condition in which high doses of pain medications actually increase the patient’s pain. He needed to get off of the narcotics. While this conclusion was easily reached it was not easily implemented. He had a complex medical history and he needed an expert to aid in the weaning process.
I called several physicians on his behalf, including three different pain doctors and a specialist in addiction. All of them agreed that he needed to go through detoxification but none of them were interested in supervising the process. Even the weaning doses were higher than they felt comfortable prescribing. It took dozens of phone calls and hours of work before I was able to arrange a hospital admission to begin the detoxification process.
This patient reminded me of how and why patients become dependent on pain medications. His pain began with a neck injury and neck surgery that failed to relive his pain. While comprehensive pain programs that include physical therapy, cognitive behavioral therapy (a type of counseling), behavioral modification and now-narcotic medications have been proven to be most effective in managing pain, such programs are expensive, labor intensive and not widely available. His previous doctor did what most doctors do. He prescribed pain medications. When his pain persisted, out of compassion, poor judgment or both the doctor increased the dose again and again.
The patient illustrates the challenges faced in dealing with narcotic addiction. Our current health system and payment models make it easy to do the wrong thing and difficult to give patients the help they need. We desperately need to decrease our reliance on narcotics, but if we do not also work to provide better comprehensive pain care we will be abandoning millions to a life of suffering.
Update- The patient's wife informed me that he had successfully weaned off of narcotics. Amazingly, his pain levels had not increased. Sadly, they had not improved either. He has a long way to go.
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