Children Deserve Pain Treatment Too

I hope that people recognize the tongue-in-cheek nature of the title. After working as a physician in various roles over a period of 20 years, I can state with absolute confidence that the answer to the question is ‘yes’.
I’ve written numerous times about the writer/activist for the Salem-News.com web site, Marianne Skolek. I don’t know if she writes for the print edition as well, but at any rate I somehow was planted on a mailing list that provides constant updates on what she calls the battle against Purdue and ‘big pharma’.
People with a stake in the outcome of this battle may want to stay current, and even see if their Senators are involved in the process. The investigation was launched in early may, by the Senate Committee on Finance, and at this point has asked for documents from several pharmaceutical companies, including Purdue, the manufacturer of oxycontin– a medication that has become the focus for most of the wrath of those affected by opioid dependence. The investigation will include a number of groups whose missions are (or in some cases, were) to advocate for pain relief, including the American Pain Foundation, the American Pain Society, the American Academy of Pain Medicine, the Federation of State Medical Boards, the University of Wisconsin Pain and Policy Studies Group and the Joint Commission.
I consider it part of the human condition, the way we push in one direction for some period of time, and then realize (with surprise!) that we pushed too far, and need to push back. Years ago a Newsweek article warned that an emerging ice age doomed the Earth. Suggestions for saving the planet included covering the polar ice caps with soot, in order to absorb more of the sun’s precious heat– although the article pointed out that growing seasons had already been severely limited in most parts of the world, and famine was just around the corner.
We all know what happened to THAT disaster. And then last week, Dr. James Lovelock, a leading doomsayer of the global warming movement, pointed out that many of the disastrous outcomes predicted by himself, featured in Al Gore’s movie, um…. haven’t happened… and to the chagrin of many, he wrote that most of the disasters that were predicted are unlikely to occur. Read for yourself. Never before were so many people so disappointed by good news.
I’m running off topic, I know, but it is hard to observe the dramatic swing on pain relief without recognizing the broader pattern. For those confused about the pain isssue, you have reason to be confused. About 15 years ago I worked as an anesthesiologist, when the Joint Commission on Accreditation of Hospitals made their 3-year site visit to our hospital. Hospital administrators hired consultants to find out what THAT year’s big issue was— e.g. hospital acquired infections, patient privacy, rights of those with disabilities…. and found that the hot-button issue was ‘undertreatment of pain.’ Little diagrams were dispensed to every patient room, showing the smiley-face guy with an expression ranging from happy to miserable, in case a person was experiencing pain but unable to speak– allowing the person to point to the appropriate picture instead. Key personnel were told to make it abundantly clear that we all take pain VERY seriously, and we do all in our power to avoid undertreatng because of, for example, fear of addiction. Studies were widely cited that claimed that only 7% of people with true pain become addicted to opioids.
One or two textbooks became the authority on opioid prescribing, introducing a new term– pseudoaddiction– which refers to a condition of drug-seeking behavior caused by under-treating pain, rather than by true addiction.
I know that I have to pull all of this together at some point. The easiest way for me to do that is by directing people to the latest article by Ms. Skolek, where she suggests that doctors have been influenced to promote narcotics because of grants from the pharmaceutical industry. Similar accusations have been made by others, including a series of articles by the Milwaukee Journal Sentinel that accused the University of Wisconsin School of Medicine of promoting opioids in return for millions of dollars.
I respect the efforts of another group I’ve described– PROP, or Physicians for Responsible Opioid Prescribing. Their efforts have been promoted by Ms. Skolek to some extent, and vice versa. I do not know of any formal relationship between PROP and Ms. Skolek. But I hope that PROP’s efforts take a more reasoned approach than the latest article by Skolek, where she compares Purdue Pharma to Adolf Hitler. Why? Because among the many clnical trials by Purdue is one that studies the use of potent opioids like Oxycontin in children and teenagers. Some of the most sobering experiences of my medical training were at Childrens Hospital of Philadelphia, providing care for brave, hairless children, knowing the years of pain that awaited them– if things went well.
I think I’ve provided enough background and links to start interested parties off on their own holiday reading. Yes, there is an epidemic of opioid dependence in this country and elsewhere. There are many reasons for this epidemic, and MOST of the reasons have nothing to do with the marketing tasks used by Purdue decades ago– for which they have paid dearly. While there are clearly areas where opioids are overprescribed, and in some cases grossly overprescribed, it would be a shame if the current swing in regulatory sentiment takes us to the point where doctors are afraid to provide pain relief for people who are suffering. This is already the case in some instances; people labelled as ‘addicts’, no matter the length of their remission, are likely to wait a long time for their first dose of narcotic, should they be unlucky enoough to develop a kidney stone.
I’ve spent a great deal of time and energy defending those poor souls, and discovered, sadly, that most doctors just don’t care about the pain experienced by recovering addicts. But there is a saying, also often referenced to the Holocaust, referring to mistreatment of others being ignored, until eventually similar mistreatment is directed at those who didn’t care about others. There are times when attempts to ‘cure’ go too far. Suggesting that methods of pain relief should not be investigated, clarified, and perfected for children is going a bit too far.

The Downside of Methadone

An Article by Mike Berens and Ken Armstrong, Seattle Times, discusses some of the problems with using methadone as a first-line treatment for pain:
When it comes to battling pain, Washington health officials have encouraged doctors to reach for methadone, a powerful and inexpensive prescription drug. For the past decade, the state has declared methadone to be as safe and effective as any other narcotic painkiller.

Methadone

But in a striking reversal that has gained momentum this week, doctors are receiving stark warnings that methadone is riskier and more dangerous — a drug of last resort — because it’s unpredictable and poses a heightened risk of accidental death.
“It’s a dangerous drug because it accumulates in the body and people die in their sleep,” Dr. Jane Ballantyne, a pain specialist at the University of Washington, said Friday. “It’s very tricky and difficult to use safely.”
Ballantyne and the university are helping spearhead a series of state-sponsored training programs to educate physicians, pharmacists and advanced nurse practitioners about the risks of pain drugs.
Earlier this week, while delivering a continuing medical education course for dozens of physicians and other medical professionals at the university, Ballantyne presented a slideshow in which she cautioned that methadone “should be considered a last option opioid, never a first line opioid.”
The state’s effort is a response to a Seattle Times series, “Methadone and the Politics of Pain.” The investigation, published in December, detailed that at least 2,173 people in Washington have died from accidental overdoses of the drug since 2003.
The Times found that year after year, a committee of state-appointed medical experts sanctioned methadone, empowering the state to designate it a “preferred drug” and steer people with state-subsidized health care — most notably, Medicaid patients — to the drug in order to save money.
The state has included only two drugs, methadone and morphine, on its preferred list of long-acting pain drugs.
During the committee’s meetings, officials from state agencies that have a financial stake in methadone’s selection consistently deflected concerns about the drug.
Methadone’s death toll has hit the hardest among low-income patients. Medicaid recipients account for about 8 percent of Washington’s adult population but 48 percent of methadone fatalities.
After the series, the state sent out an emergency public-health advisory that singled out the unique risks of methadone.
Medicaid officials faxed a health advisory to more than 1,000 pharmacists and drugstores about methadone, as well as about oxycodone, fentanyl and morphine. The state Department of Health mailed advisories to about 17,000 licensed health-care professionals.
The health advisory confirmed that Washington ranks among states with the highest rates of opioid-related deaths, exceeding the number of deaths each year involving motor vehicles.
Most painkillers, such as oxycodone, dissipate from the body within hours. Methadone can linger for days, pool into a toxic reservoir and depress breathing. With little warning, patients fall asleep and don’t wake up. Doctors call it the silent death.
Ballantyne noted that methadone is an indispensable drug and plays an important role in the treatment of many patients. However, due to the heightened risks, methadone should be prescribed only by those with extensive training and experience — and only after every other option has been exhausted.
Dr. Jeff Thompson, chief medical officer of the state’s Medicaid program, now readily agrees that methadone use carries unique risks and that it should not be the first choice if other drugs are equally suitable.
He said physicians are stepping up efforts to unravel the long-term impact on the body from prolonged use of prescription drugs now that Washington’s new pain-management law has gone into full force beginning this month.
The groundbreaking law requires practitioners to follow new standards for treatment and record-keeping. It also requires prescribers to consult with state-certified pain experts when narcotic dosages reach higher thresholds.
While the law’s goal is to lower doses and, if possible, wean patients from narcotic pain drugs, doctors are finding the task more difficult than hoped, Thompson said.
For instance, methadone patients can suffer prolonged withdrawal symptoms, like nausea and depression. With most pain drugs, withdrawal subsides within a week. Methadone’s grip can last for months, even years, he said.
State officials will review methadone’s role on the state’s preferred drug list during a meeting next month.
“I think we’re going back and relearning how to treat pain,” Thompson said.

Suboxone, depression, anxiety, and pain

A question about Suboxone and mood:
I came across your website while looking for answers to Suboxone. I was wondering what you thought of a patient being prescribed Suboxone for depression and anxiety disorder? I have tried almost every antidepressant you can think of. I have also tried lithium and depakote because my doctor (at the time), thought I may have bipolar II. I recently started taking Suboxone and I feel like a brand new person who now is excited to wake up in the morning and do the things I need to do with enjoyment. I no longer have chronic headaches, IBS and constant anxiety. I was never addicted to pain killers (hydrocodone), which was given to me a few times for an injury and also severe migraines. I did however, like the feeling of the hydrocodone but was unable to get a doctor to prescribe it to me for my problems. I am very leary about taking an opiate, especially after reading many of the questions and comments on your website. I am doing well on the minimum dosage (2mlgs) once everyday. I would really appreciate your thoughts and opinion on this. Sincerely, “leary about taking Suboxone for help with my depression and chronic anxiety disorder”. Thank You.
My Response:
Thanks for writing. There has been a number of case reports over the years describing the use of various opiate agonists for treating depression. There are also studies using buprenorphine, the active substance in Suboxone. A couple years ago, a writer named Lauren Slater discussed her use of Suboxone for her own depression in an article in Elle magazine– the response was mixed, as would be expected. Some people welcome the idea of using opiate narcotics to treat depression, but the general medical opinion is against that use.
All opiates that have agonist or partial agonist activity do have some euphoric effect. The problem with all of these medications is tolerance; the effects wear off over time. I have observed the effects of Suboxone in a number of depressed opiate addicts; most patients will have a bump up in their mood, but the ‘bump’ tends to go away over time and the depression tends to return. Because of the unique actions of buprenorphine however, I know that there are patients out there who are taking it mainly for their depression, hoping that the tolerance doesn’t take away the mood effects completely. Since buprenorphine seems to be helpful for pain for a longer period of time than one would expect, perhaps the mood effects will last longer than we expect as well.
In general a patient who does not get better with medication should at least consider the idea that they have personality factors standing in the way of happiness. Borderline personality is often confused with bipolar; nobody asks for personality disorders and there is nothing to be ashamed about… I suggest you read online about ‘borderline’ and see if anything fits. People with that condition have horrible episodes of depression and suicidality, and they don’t respond well to medication, but a bit of insight into their condition can go a long way toward easing their pain.
SD

Pain Relief Network

I am moving the post below from the comments section to here because many readers will benefit from the information. As a doctor treating chronic pain I can attest to the problems and challenges from all angles. I worry about leaving patients in pain– but at the same time I know that for long-term pain, opiates are rarely the answer because of tolerance and the eventual erosion of personality that occurs with opiates. I also worry about regulators and licensing boards. I also worry about contributing to the problem of opiate diversion– nothing makes me more angry than the thought of a patient that I trust and believe going out and selling meds that I have prescribed for pain. In my home town, the local health system tries to scare the docs into not prescribing pain meds, putting the burden on the few docs in town who work independently. With all of these concerns it is good to see efforts to bring the issues involved in treating pain out into public awareness. I also am optimistic that buprenorphine, the active ingredient in Suboxone, will make a big difference for a number of patients struggling with chronic pain.
The Comment:
The readership here might be interested in the following item from War on Doctors/Pain Crisis blog, which has links to other medical-blog discussions of buprenorphine for pain from the Pallimed blog. Hopefully some of you will find this interesting.
“High Dose Transdermal Buprenorphine for Pain”– Barutell et. al, Pain Practice, 2008.
which discusses the presented Abstract from a large multi-center study in Spain published just recently. Find also links to the discussion on PRN’s Chronic Pain Forums, which are informative, and to the discussion on Pallimed mentioned above.
Enjoy! Thank you for your efforts with this blog.
Sincerely,
..alex…
doctorde[email protected]
Alex DeLuca, M.D., MPH
Senior Consultant, Pain Relief Network
http://painreliefnetwork.org/
http://doctordeluca.com/wordpress/

Chronic Pain and Addiction

The interface between chronic pain and addiction is very complex. Pain becomes worse the harder one looks at it, and taking narcotics tends to draw attention to the pain… so as a broad generalization patients don’t do as well on pain meds as off. At the same time, patients will claim that is not true, even as they suffer depression, become overweight, lose friendships… Again, things are already complex, but if you throw in a bit of denial things really get complicated.
An interchange on the pain topic:
Question:
Dear Sir,
What happens when a chronic back pain ( 2 surgeries ) woman attempts to detox off oxycontin to methadone, gets addicted, detoxes to suboxone, and then can not get anyone to listen to her as she struggles to detox off suboxone? My sister would like to get off all opiates and they want her to detox over months and she is not receiving any psychological support from her psychiatrist. In addition, at 10 mgs there is little pain relief.
Suggestions?

Answer:
Thanks for writing. Such a tough situation—and unfortunately a very common situation as well.
My first thought is to make sure that everyone understands what she is dealing with. You mention ‘detoxing’ off oxy to methadone– methadone is an opiate ‘agonist’ just like oxycodone, meaning that then both do the same thing in the brain—they both mimic endorphins and activate the ‘mu’ receptor for opiates. Some people use methadone, some use oxycodone, but they are interchangeable for the most part. Yes, oxy may have a bit more rapid onset and so it is a bit more addictive, although they both are so additive that the difference doesn’t matter much.
You may find other opinions—maybe not—but I would say that if she has been addicted to those medications, she will always have problems with opiates. Like everyone else I hate to assign a lifetime diagnosis to people, but I just NEVER see a person who has been addicted to opiates walk away from them without a major change in life that includes going to 12 step meetings regularly. Even then, staying clean is very difficult for most people, and their opiate addiction tends to relapse repeatedly. In science lingo (I notice your PhD), attending meetings and taking other steps in recovery are necessary, but not sufficient, to stay clean.
Pain makes addiction much more difficult to treat. The pain will change along with opiate cravings. Patients get offended when I say this, but they shouldn’t—to them the pain is the same whether it is coming ‘purely’ from damaged tissue vs coming from deeper brain centers involved in addiction. I have watched many times as pain patients ‘talk themselves’ into needing opiates for a pain that they never used to need opiates for. Because of that interaction, people with chronic pain generally do WORSE on opiates than those who take nothing! The people on nothing will automatically suppress the pain—try to ignore it—whereas people on opiates will focus in on the pain and exaggerate it. Functionally the same thing happens. Patients will ask for opiates, saying that they need them to work, but if you did a blind observation you would see a clear difference in the other direction—that the people on opiates are less functional. They are also less happy, have less energy, and have worse sleep patterns.

Suboxone has a ceiling effect, so that the dose/response curve isn’t a straight line but rather levels off at about 2 mg of Suboxone per day. Increasing Suboxone beyond that amount reduces cravings but does not reduce pain. I recommend 8-16 mg for most people as the ideal dose to get the maximum suppression of cravings. Patients always claim that more Suboxone will help, and they can abuse Suboxone as well—but double blind studies show that it is all in their heads as a placebo effect, and taking Suboxone , 8 mg once per day in the morning, will work as well as any greater or more frequent amount.
I recommend that she try to understand the nature of her situation—the dead end offered by opiates, and the life long nature of addiction—and consider staying on a stable dose of Suboxone long term.
A very tough situation– I wish you the best.
SD