On Increasing Opioid Prescriptions

A question:

If it is the case that "[t]he amount of five major painkillers sold at retail establishments rose 90 percent between 1997 and 2005," why is it that pain remains so undertreated?

Given that pain and pain management is my dissertation topic, I am quite familiar with this literature, and I can say with some degree of confidence that, for example, an elderly chronic pain patient's odds of receiving appropriate pain management are not high.  Yet this is not because we currently lack appropriate and at least somewhat effective treatments for most (but not all) kinds of pain.

Consider this nugget buried at the bottom of the article:

"Spooked by high-profile arrests and prosecutions by state and federal authorities, many pain-management specialists now say they offer guidance and support to patients but will not write prescriptions, even for the sickest people."

This can be hard to believe, but it is absolutely true that many pain management experts refuse to prescribe opioids, even while opioids are considered frontline therapy for many different pain conditions. 

And I will here register my own view that some of the primary reasons pain remains undertreated -- and prescribers refuse to prescribe opioids -- are not because of the regulatory climate.  With rare exceptions, the ethics and policy of pain management are almost exclusively reduced to a discussion about enforcement and regulation.  This is a mistake, IMO.  Enforcement and regulation are very important, but legal culture is itself dialectic, which means cultural and social factors contribute to the particular form such enforcement and regulation takes.

Without giving too much away, analysis of these cultural and social factors is the core of my dissertation.

BLOGVERSATION: Healthcare Economist, Managed Care Matters, Health Law Prof.

Comments

[Nickie Coby]

I am a patient with Complex Regional Pain Syndrome, which is incredibly
painful and can be very difficult to treat. One thing I think is missing in
the discussions of opioid prescribing is the measurable effect they can have on people's lives. I DID NOT want to start taking the opioids my doctor
prescribed. I like even less that we have to increase them every so often. But, without them, my body couldn't function. I couldn't go to school to be
a social worker. When opioids are used properly, they increase function. We
adjusted medications last week, and are making other changes which are
appropriate.

After a summer of not feeling hopeful (admittedly hard to quantify), being too nauseated to want to eat, not being able to go shopping except online
(which my mother admitted she missed doing with me) and poor sleep which
requires use of Ambien many nights due to the pain, function is improving. I wonder why the simple idea of properly used opioids increase function,
while psychological dependence or addiction decrease function which I first read in Scott Fishman's "The War on Pain" isn't discussed in the public?

Speaking from a patients' perspective, I'd say that publicizing that idea,
instead of the hysteria of the War on Drugs and "Ohmygosh pain killers are evil and all over being used too much" would be helpful.

In high school health classes, we learn that addiction is harmful. But I don't ever remember learning basic ways to care for pain, or even
understanding how some basic pain killers work. Maybe, if you went to the
school nurse, you got a bit of counseling on what to ask a doctor about
using ADvil, but I don't remember pain being discussed in school. I, and most of my peers (I'm a junior in a BSW program) have to learn about pain
ourselves. We're the future caregivers and leaders. I think some of the hysteria could be prevented if students actually learned about healthy attitudes toward pain.