By Victor S. Sierpina, MD
With pressure from every side, doctors like you and me are pressed to taper, stop, or refuse to start habit forming pain medications. Our EPIC electronic medical record system now pushes us to inquire the Texas Prescription Monitoring Program prior to our electronic dual authentication signature for any controlled substance. On face value, this is highly sensible in the context of tens of thousands of deaths annually from opioid overdoses in the USA. The story turns out to be a bit more complicated, as you might expect.
I would like to share some key points from a peer-reviewed article in the December 2019 Journal of Family Practice by Dr. Bennet Davis and colleagues, “A Patient Centered Approach to Tapering Opioids”:
- Patients seek the antianxiety and antidepressant effects of opioids
- Patients experience pain unrelated to tissue damage
- Patients suffer from opioid use disorder (OUA) and complain of pain to obtain opioids by prescription
- Patients are obtaining opioid prescriptions for people other than themselves
A high percentage of those so-called drug-seekers and opiate addicted people are also suffering from anxiety, depression, post-traumatic stress disorder (PTSD), or other psychiatric conditions. They don’t seek pain meds to get a high but because their underlying mental health problems have been underrecognized, undertreated, or overlooked in the context of their so-called “drug-seeking.”
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In fact, tapering or stopping opioids in veterans did not reduce overdose deaths but resulted in more suicides. Patients whose opioids are discontinued often switch to heroin or the synthetic opioid fentanyl with worsened outcomes. There was a 71% in drug overdoses from these street drugs from 2013-2017. Overdoses from prescription opioids during a similar period were still up, but only about 30%.
Practice recommendations for patients with chronic pain are:
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- Screening for developmental and adult trauma
- Referral for in-depth behavioral health evaluation
- Referral for addiction medicine treatment
Unfortunately, there are major barriers to these sensible and evidence-based recommendations, given often limited insurance coverage for and availability of mental health and addiction services,
Another barrier is the stigma of mental health problems in general. It is more socially acceptable for a brave, returning fighting woman or man to report pain from a physical injury rather than a psychological issue like post-traumatic stress, depression, anxiety, panic attacks and the like. Similarly, civilians with these conditions are often suppressed from seeking care by family and culture.
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Opiates may take the edge off mental health conditions but don’t really solve the problem but add the additional problems of substance use disorder and potential addiction. Then can come all the downstream issues of unemployability, homelessness, hopelessness, legal problems, overdose, suicide.
Is there a solution? The Academic Consortium for Integrative Medicine and Health released a white paper proposing entitled, Evidence-based Non-Pharmacological Strategies for Comprehensive Pain Care (https://www.researchgate.net/project/Evidence-Based-Nonpharmacologic-Strategies-for-Comprehensive-Pain-Care-The-Consortium-Pain-Task-Force-White-Paper) documenting integrative approaches for pain management. Subsequently, Medicare has recently approved payment for acupuncture services for those with chronic low back pain. This is good news that perhaps the ice is beginning to crack in the insurance system to allow patients choice, access, and payment for safe and effective integrative treatments for pain.
Acupuncture has also found its way into the Veterans Administration System for management of PTSD, post-concussion syndrome, and chronic pain with reimbursement for care for wounded veterans using this ancient system of care.
Mind-body therapies, botanicals, the anti-inflammatory diet, movement therapies like yoga for back pain, tai chi, and mindfulness training all have evidence of effectiveness.
Can our health care system adapt to paying for such therapies? The historic response has been, “No, they add costs and are not that well proven.” However, such integrative therapies can, in the long run, save costs, reducing risks of not only opiate addiction but reducing costs for unnecessary surgery, imaging, and other highly profitable interventions. Such conflicts of interest in established medical profit centers push back powerfully against such low cost and effective interventions.
Can we find the middle path? Perhaps the Medicare decision to support treatment for chronic low back pain is the crack in the cosmic egg that allows the light to come through.
At the very least, we might all agree that we need a stronger mental health safety net. We need to create an early identification, referral and treatment access program, de-stigmatization of psychiatric problems, outreach to homeless folks and vets who are often primarily mentally ill and secondarily substance abusers and the concomitant economic impairments and downright poverty.
Bottom line:
A patient-centered approach emphasizes understanding why the patient is taking opiates, engaging complementary and integrative specialists, addressing underdiagnosis of psychological trauma, and creating a quantum leap in access to trauma-specific behavioral health treatment resources. Such system-based changes require including a full range of treatment options with a full commitment of policy makers in health care and government.
It also includes YOU. Do something. You know what it is.