Foreign Affairs published an article in their May/June 2018 issue entitled “Opiods of the Masses: Stopping an American Epidemic from Going Global.” Global health often takes a back-seat in this journal, especially with issues such as North Korean aggression and populist nationalism on the rise. The publishing of this article, especially in an issue discussing the decline of democracy, shows just how urgent this issue is to the US and countries across the globe.
The Trump administration has declared the US opioid crisis a national emergency. With ? people dying annually from overdose, a national emergency is an understatement. At this point it is too little too late. The grand announcement of a “national emergency” should have happened years ago. Now hospitals, physicians, and the government are back-tracking, trying to control a problem that has been growing out of control for several years.
People use for different reasons. Many patients have legitimate chronic pain. However, the pharmaceutical companies have spent millions and millions of dollars lobbying for the use of narcotic pain medications as treatment for chronic pain. The problem is that the longer patients use opioids, the more likely the patient is to become addicted. As they continue to use, they become tolerant of medications such as Percocet and have to begin using stronger medications such as morphine, dilaudid, and fentanyl.
Opioids are also a cheap high. Patients on heroin can obtain narcotic pain medications from people selling prescription medications to either increase their high or obtain something to use while they wait to use heroin. “Drug-seekers” can see multiple providers, begging for pain medication for either real or imagined pain. It erodes the trust between physician and patient. Physicians become suspicious or dismissive of patients, even those who are truly suffering from pain. Patients become frustrated with lack of pain control.
I’ve seen this epidemic first hand working for orthopedic surgeons. Joint pain hurts. Patients can spend years with pain made worse with simple activities such as walking. Instead of addressing the issue with orthopedic treatments such as physical therapy, cortisone shots, or even surgery, patients are given narcotics as a bandaid, a temporary patch for the pain. By the time they see an orthopedic surgeon, they are already addicted or tolerant of post-operative narcotic pain medication like Norco. Once I met a patient on 60 mg of morphine daily for knee pain. She presented to clinic complaining of the knee pain. One knee had already been replaced and she was looking to replace the other. The patient began to describe her pain while rubbing the knee with a long vertical scar. We asked her to clarify which knee hurt. She paused, then realized she was rubbing the wrong knee. The morphine was so strong that she was unable to differentiate between her painful and non-painful knees.
Another patient became the victim of a primary care physician who gave out narcotics like candy, rather than addressing the true cause of her pain. She had severe degenerative scoliosis, which progressed over 3 years. By the time she reached our clinic, she was unable to stand up straight. Walking, sitting, standing, and lying down were all painful and difficult. The PCP was adamant that spine surgery would worsen her pain, and so he continued to prescribe narcotics until the patient became addicted to heavy narcotics. She was very reasonable, but unfortunately weaning her off the narcotics was a painful and unpleasant process. Her original doctor’s license was eventually revoked.
I live in Arizona, where the government has made moves to control and monitor the opioid epidemic. Patients often are required to obtain narcotic pain medication from pain management specialists, who sign contracts with the patient agreeing to prescribe certain medications provided the patient remains compliant with certain criteria. If patients take their pills in a way other than prescribed, the contract can be terminated and the patient will be “fired.” There is also a useful database for healthcare providers indicating when and where a patient last obtained narcotic pain medication. Unfortunately, I have only met one physician who uses it diligently.
So where does the medical student (or pre-med) fall into this overwhelming issue? As we learn to care for our patients, it is difficult to reach a happy medium between relieving a patient’s pain and a healthy dose of realism to protect ourselves and our patients from drug-seeking individuals. The methods of controlling opioid addiction often focus on how to address the problem in the here-and-now, if only to decrease the substantial number of deaths by overdose. As the future physicians of tomorrow, we are the key to prevention.
Our role in the opioid crisis lies in education. We must educate ourselves on proper pain control without over-relying on narcotics. We must familiarize ourselves with the laws and measures taken to protect healthcare providers and their patients. We should seek out physicians who take responsibility for their patient’s pain, while monitoring for suspicious activity. Examples include the physician who checks the Arizona opioid database prior to prescribing narcotics or the bariatric surgeon who developed a post-operative pain management plan that does not involve narcotics, which patients agree to in a signed contract. These are the physicians we should seek out to enhance our education and future practice. I would also recommend shadowing a pain management specialist, the type of physician on the front-line of this crisis. Physicians specializing in chronic pain can also provide a unique perspective on alternative methods of pain management. I shadowed a specialist for Multiple Sclerosis, a disease which can cause both neurological deficits and pain. Not once did i ever hear him even discuss the possibility of narcotics; yet his patients’ symptoms were managed and they were satisfied with their care.
It is difficult for students, who do not currently hold responsibility for patient treatment and care, to imagine ourselves in the predicament that faces current healthcare providers. This problem is not so simple as avoiding prescribing narcotics (though this is a key strategy). We must learn through their experiences, mindfully watching for the strategies that work and the mistakes they have made. Meanwhile, we must also educate ourselves on safe practices, laws, and resources to address addiction and prevent proliferation of opioids. We are the future of medicine and the future of addiction prevention.