The following editorial was written by Dr. Mark Albanese, a psychiatrist, educator, and scientist who advocates for evidence-based care of opioid dependence and other expressions of addiction. This editorial is part of our Special Series on Opioid Dependence and Recovery.
Unless you have Rip Van Winkled through the past few years, you know that opioids have become a problem for our country. There has been a lot of shouting and hand-waving about who is to blame. An especially popular explanation is physicians who have been overzealous in prescribing opioid pain medications. This is ironic for me, since I am old enough to remember a time in healthcare when physicians were “guilty” of not adequately treating pain. It was thought to be such a problem that pain was declared to be “the fifth vital sign,” and the healthcare facility that did not continuously monitor and address the pain of their patients did so at their own risk – including loss of accreditation and funding. I have somewhat jokingly said that you cannot get beyond the lobby of an American hospital without somebody asking you to complete a pain Likert scale (“1 being the least amount, and 10 being the worst you have ever had.”), complete with facial diagrams.
I do not mean to make light of pain, but this brief historical interlude underscores what I think is a major issue for medicine and society in general. We don’t do moderation very well. Drive through any city in the United States and it seems like there is a gym on every other block, and around the corner or across the street a fast-food joint in contradictory juxtaposition. The message on one hand seems to be that you are not serious about working out if you don’t start your day with a couple of hours on the treadmill, and on the other hand it appears that you have a God-given right to comfort yourself whenever you want with whatever artery-choking delicacy you see fit. The true path for most of us, of course, is probably somewhere in between. A half hour of moderate (there’s that dreadfully unsexy word again!) exercise 4 or 5 times a week is probably what the doctor ordered. And an occasional cheeseburger is not the end of the world.
Yet, the societal message seems to mock the idea of moderation. This message hits the people I treat – patients who have an addictive disorder – especially hard, since they do all-or-none better than most and the stakes for them are very high. Some of my patients in early recovery would like to be running marathons (so would I, but it is probably never going to happen!), but struggle with the motivation to walk around the neighborhood after dinner. They have a tough time going from no exercise to just some exercise on their way to achieving that admirable marathon goal.
We are at risk of experiencing this same disregard for moderation when it comes to the issue of pain and using opioids to treat that pain. Now that both federal and state governments have opioids in their crosshairs, I get concerned that the proverbial pendulum is about to swing back to where it was when I was in medical school, such that pain is not adequately treated. Witness a recent Boston Globe headline: “Strict opioid laws hit chronic pain sufferers hard.” The reality is that the job of healthcare providers is not to eradicate pain but to relieve it in order to restore maximal function. Sometimes that will mean using opioids. This does not mean that opioid prescribing practices should not change. Let’s just be guided by the evidence when making those changes. Let’s avoid hysteria and reflexive measures. And let’s avoid extreme approaches, like deciding that “I will never prescribe opioids!” Rather, let’s work on better defining both those clinical situations where opioids should be used and those times when they are counter-productive.
And the story is not just about opioids. Much of the pain confronting medical providers is bound up with psychosocial factors like comorbid psychiatric conditions including trauma and depression. And these are compounded by a predisposition to addiction. Merely turning off the opioid spigot will not relieve the suffering of these complex patients. We need a comprehensive, integrated approach to pain, addiction and psychological suffering. Let’s make an investment in this kind of comprehensive care – in addition to implementing measures such as limiting the length of initial opioid prescriptions, mandating physician utilization of prescription databases, and sanctioning physicians who fail to comply with the new guidelines.
I would propose, in addition, that there are at least two other factors that are helpful in this time of crisis. One is hope. I don’t think that anybody would disagree that too many people—a disproportionate number of them with most of their life ahead of them–have overdosed and died. While opioid use disorder is indeed a potentially lethal disease, the reality is that most people with the disorder do not overdose. Many people make a choice for treatment and recovery. We are fortunate to have medications proven over decades of use to help stabilize people with opioid disorders, allowing them to engage in the recovery process. Although these medications are underutilized, every day I meet people who decide that there are relationships more important to them than their relationship to oxycodone or heroin. I am reminded of the young man who tearfully (in truth, we were both crying!) told me that he could not put his grandmother through more pain—she had lost her daughter (his mother), and more recently her granddaughter (his sister) to heroin overdoses. His death would kill her, thus he came to me to be enrolled in methadone treatment.
The other ingredient that we need to add to the mix is generous amounts of compassion. At the core of addiction is profound shame. It does not take much for the shame to revive and self-esteem to spiral downward. We all have the ability to make this happen, consciously and unconsciously, with both our words and nonverbal messages. I think that the process is more painful when it involves a healthcare provider. Maybe that’s because we are supposed to be non-judgmental and brimming with compassion. So, an addicted person is left thinking that “if I cannot get compassion from a caregiver, there must be something unforgivable about me.” Today, a patient about 9 years in recovery told me that she has switched pharmacies because “I got tired of the pharmacist at the other pharmacy rolling her eyes and treating me like a criminal whenever I dropped off my Suboxone script.” The pharmacist at the new pharmacy “smiles at me and asks me how I’m doing.” Another of my patients, in recovery about 5 years, at my urging, finally got himself to the GI specialist for a work-up of his appetite change and significant weight loss. He no sooner sat down than the physician told him that if he was looking for opioids he should know up front that he had come to the wrong place. The patient fled that office and presented to his next appointment with me beside himself. He somewhat rhetorically asked me: “Can’t he see in the record that I’m on Suboxone??!! Can’t he see that I’ve lost 60 pounds??!! Why would I come to a hospital where they can see my history to seek pain meds??!! I could get those anytime, but I’m trying to do the right thing!”
A lot of factors have gone into getting us into this opioid mess, so it is no wonder that it will take a multi-faceted approach to get us out. Finger pointing, blaming and tripping over ourselves in a headlong rush to implement unproven interventions in an attempt to prove how seriously we are taking the problem is not as helpful as keeping our heads and both utilizing evidence-based approaches and further developing new approaches to the complex suffering of those with pain. And in the process, let’s remember our humanity, which is defined by hope and our compassion toward the most marginalized in our society.
Rivkah Lapidus June 27, 2016
Well done, Dr. Albanese. It is important also to not let the rehab process be shame based with an all or nothing approach to recovery. And please, as part of any discharge from abstinence-based rehab, it is not “enabling drug use” to remind patients that their tolerance has gone way down. What they used to be able to handle (more or less) might be fatal.
Rivkah Lapidus, Ph.D. LMHC
psychotherapy, art, harm reduction and moderation
rivkahlapidus.com
Juliana Zee, Psy.D June 27, 2016
I couldn’t agree more. I have seen a pcp suddenly stop prescribing an opioid for a patient who had taken them for a long time for diabetic nerve pain, in a panic about the opioid crisis. My patient had weaned herself off of Percocet, the pcp then cut off the fentanyl patch. It felt punitive to the patient, and sent her into withdrawal. There has to be a more reasonable approach.
Ron Bergman June 27, 2016
Yes. Compassion: More powerful than any opioid will ever be. And any addiction treatment without it at its core, is doomed to fail. Dr Ron Bergman
strayan June 27, 2016
‘Overprescribing doctors’ are largely an invention of the White House ONDCP and DEA. These bureaucracies are experts at finding scapegoats (today it’s the doctors) for the failures of their drug war (in this case an increase in opioid overdoses and associated harms). They will shift the blame wherever possible.
Up until recently the ONDCP were vehemently opposed to the distribution of sterile injecting equipment and the lifesaving overdose reversal drug naloxone. They made no secret of this and it is all on public record e.g.
“Dr. Bertha Madras, deputy director of the White House Office on National Drug Control Policy, recently told National Public Radio she opposes the distribution programs because—and hold on to your hat for this one—she believes life-threatening overdoses are an important deterrent to drug use.
“Sometimes having an overdose, being in an emergency room, having that contact with a health care professional is enough to make a person snap into the reality of the situation and snap into having someone give them services,” Madras said.” http://www.foxnews.com/story/2008/02/25/straight-talk-should-tax-dollars-be-used-to-help-drug-addicts-avoid-overdoses.html
“There is no federal funding for needle-exchange programs. The White House Office of National Drug Control Policy opposes them.” http://usatoday30.usatoday.com/news/nation/2006-10-02-nj-needle-ban_x.htm
I now watch on in awe as the ONDCP and DEA scramble to blame doctors when this mess unfolded ON THEIR WATCH. For Pete’s sake the DEA are the ones who set the annual production quotas for opioids! Between 1993 and 2015, the DEA rubber stamped continuous increases in opioid production (which jumped from 3.5 tons to 150 tons in this period): https://www.washingtonpost.com/news/powerpost/wp/2016/06/23/is-dea-a-bad-guy-in-opioid-addiction-fight/
Edward J. Khantzian July 3, 2016
Mark, you cover a lot of ground and you cover it well. Your hope on behalf of patients comes across as well as your compassion. We need more voices like yours.
Ed Khantzian
maurene merritt July 4, 2016
Thank you for bringing to light the importance of hope and compassion, that such knowledge is truly at the very heart of caring for our patients. Maurene Merritt, RN
Lynda Richardson July 31, 2016
In all of this the problem not ever addressed never spoken about is honest not addicted suffering pain patients by those that refuse to understand what we are dealing with. While addicts continue to use & even go to the doctors to get long term opioids they blame for the problem. Pain patients are taken off long term treatment left to go to the streets or suicide for our pain relief. As it continues only getting worse for those on long term treatment with opioids. Those that have been successful without any problems with abuse or addiction. We are being forced off our treatments but the problem is the pain opioids relieved gave us better quality lives is completely ignored. Our pain does not magically go away after years decades just because opioids are not being prescribed anymore. We are being forced to suffer it is inhumane a cruel torture. When pain patients are cut off flat and die of unrelieved pain and withdrawal that is causing heart attacks & strokes. It has happened over & over in members of our pain groups but no one publishes those tragedies. Are we being ignored so when the death toll of pain patients gets so high they can’t ignore it anymore they can claim they had no idea we were suffering & dying? What are we to do? My pain doc of 10 years provided high dose opioids for 10 years with no problem. Now I feel I am looked at like a stranger like I have been doing something wrong. The ins is cutting me off after 10 years of treatment & putting my life in danger all & only because of other peoples abuse & addiction problems. It’s not because of anything i have done my medical record is clean of any wrong doing ever. All have ever had was a speeding ticket but treated like we are criminals. Can someone please explain I am at a loss how can pain doctors suddenly not back up their own treatments? How & why do pain patients have to be expected to live in so much pain now? It’s the same life altering life destroying leaving you crippled curled up in a ball of misery on your bed kind of pain that got us put on opioids in the first place? If we weren’t in so much pain we wouldn’t have been taking these meds. The discrimination before was bad but now we are looked at like dirt. No one would choose this life living in pain is torture but without any pain relief that torture will be more then I can handle so what can I do? What are all of us being abandoned through no fault of our own supposed to do? We don’t have the time to wait. We are suffering every minute that’s like an hour everyday & dying before we would have in misery. How long before they decide enough of us have suffered died & killed ourselves to relieve our pain? How long till they realize they have caused the wrong people to be punished all because of other peoples actions? If pain patients would have gotten relief from all the other treatments they claim are better we would be doing it. All the trials with treatments we had to go through first before even being offered opioids for pain relief. We would have done it & I would beliving my life instead of trying to figure out how will we survive it, but none of those gave adequate enough relief. We have always been at the mercy of our doctors & public opinion and now that heavy hammer has fallen all the mercy empathy compassion is gone and we are left with nothing. If you have any suggestions for all of the legitimate suffering pain patients in our country they would be helpful We are desperately looking for an answer to our epidemic of untreated pain killing us by body failure & suicide when we can no longer wait for our bodies to fail on their own. We would be thankful for any help because our government is not listening the public can’t see beyond saving the addicts. We need help yesterday. Why didn’t anyone consider we need to have a working medication to replace opioids before we take it away? They wouldn’t take heart patients or kidney or diabetic patients medicine away they are dependent on without a working alternative to replace it. But pain patients were not considered they just took it away even though they had nothing to offer to replace it. I think they should restore all pain patients with medical records showing improved quality of life make a better medication that is equal & works as well as opioids to replace opioids and then we will happily give back all opioids, but I don’t imagine that will happen.