A common complaint among emergency room physicians surrounds the solicitation of pain medications. Nearly half a million ER visits in 2009 were due to the misuse or abuse of prescription painkillers. Several years ago I worked closely with a family physician in Binghamton who warned about patients who feigned illness to acquire narcotics – malingerers who staggered into the office with a façade of excruciating pain, only to exit with perfect gait (unknowingly captured by the parking lot surveillance camera). These wily actors, however, endanger those who genuinely depend on prescribed opioids. Over one million Americans live with chronic pain today, and more than half of respondents report little or no control over their pain. Yet, prescription painkillers are a major contributor to the total number of drug-related deaths, and the estimated number of emergency department visits linked to non-medical use of prescription pain relievers has nearly doubled in the past 10 years. The past several decades have witnessed a remarkable transition: from the neglect of chronic pain conditions and the denial of its existence; to the overprescription of opioids for every minor ache and cramp; to the now popular replacement of opioids with potent street drugs like heroin.
Pain, considered the “sixth vital sign,” is more troublesome to gauge than other indices of health. As a subjective criterion, pain is particularly difficult to measure and so is easier to fake than, for example, high blood pressure or fever. A recent study published in the New England Journal of Medicine, however, demonstrates improvements in determining patients’ levels of pain using functional magnetic resonance imaging (fMRI), which holds promise for identifying objective measures of pain. Machine-learning analyses were used to identify a pattern of fMRI activity across brain regions (a neurologic signature) associated with heat-induced pain. The neurologic signature showed sensitivity and specificity of 94 percent or more in discriminating painful heat from non-painful warmth, pain anticipation and pain recall. In other studies, connectivity analyses of functional imaging data have also highlighted the relevance of frontal cortical regions in mediating or controlling the functional interactions among key nociceptive-processing brain regions that subsequently produce changes in perceptual correlates of pain, independent of changes in nociceptive inputs. New technological developments will allow researchers to assess changes in the spinal cord neuraxis, which has been a challenging region to image because of the low signal-to-noise ratio as a result of its size and the motion-related artifacts because of respiration, the cardiac cycle, and pulsation of cerebrospinal fluid. More work must be done to understand the role of psychogenic pain in central processing, since the mind can be a powerful activator of specific networks which create vivid experiences of pain. Nevertheless, the classic emoticon scale is still the tool of choice for grading patients’ pain from zero to 10.
There is a vast inventory of chronic pain medications that includes non-steroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants (TCAs), serotonin and norepinephrine reuptake inhibitors (SNRIs), corticosteroids, anticonvulsants and opiate pain relievers. Prescription opioids, which are often used when other medications are unhelpful, have the ill effect of instigating tolerance, dependency and withdrawal symptoms, and are often inadequate in treating chronic pain. The escalating problem of inadequately treated moderate to severe pain and the misuse, abuse and diversion of prescription opioids (which often largely offsets the perceived benefits) has created a significant problem in the American healthcare system. In 2010, the National Drug Intelligence Center (NDIC) released the National Prescription Drug Threat Assessment, which reported the costs associated with controlled prescription drug diversion occurring through doctor-shopping (getting multiple prescriptions from different doctors simultaneously), prescription fraud, and threat at an estimated of $72.5 billion per year. An enhancement to the Prescription Monitoring Program would give providers instant and meaningful access to information prior to prescribing an opioid medication, and other programs such as safe-use (education about storage and disposal) and take-back (for unused medications) programs would do great service in controlling the damages wrought by over-medication.
Prescription opioid addiction is a primary, chronic, neurobiological disease characterized by behaviors including one or more of the following: impaired control over drug use; compulsive use; continued use despite harm; and craving. Misuse of opioids (alone or in combination with other drugs) is the most common form of poisoning treated in United States emergency departments. Easy access to opioid medications, and the misconception that such medications are safer to use than illicit substances, has caused a 111 percent increase in ED visits involving nonmedical use of prescription opioids (including hydrocodone, oxycodone and methadone) between 2004 and 2008. To complicate matters further, the recent crackdown on prescription opioid medications has fueled a resurgence of heroin abuse and addiction. Heroin – which is much cheaper, accessible, and powerful than most opioids – is being trafficked from Mexico and sold at one-fifth to one-tenth the cost of black market pain pills, the average price of which is one dollar per milligram. A 100 mg bag of heroin costs just $10 per bag in New York City – about one-sixth the price of a single OxyContin pill (80 mg). Those with uncontrolled chronic pain are susceptible to this attractive trap of spending fewer dollars on a substance with a similar molecular structure to opioid medications which may or may not ameliorate their circumstance. Self-medication and polysubstance abuse is becoming more common as physicians are limiting the amount that they prescribe. Here, then, we encounter a double-edged sword: many physicians fear the harm that comes from prescribing too much, though may also reasonably worry about the dangers of having their patients seek alternative sources of pain control.
It is evident that America has a substance abuse problem, compounded by regulation at the United States-Mexico border and the slow pace of medical marijuana legalization. A renewed upsurge in heroin abuse and addiction is invariably linked to tightened control on prescription medications. Professional educational recommendations have been put forward and include: improving education for healthcare practitioners about chronic pain, pain management, and opioid use, misuse, abuse, diversion, and addiction; developing a standardized curriculum in pain management and opioid prescribing; and implementing mandatory outcome-oriented continuing education. Systemically, efforts are being made to: increase reimbursement for HCPs to accommodate the time needed to provide education, counseling, and low-cost non-pharmacologic intervention for chronic pain patients; improve systems for identifying and managing opioid misuse; institute regulatory oversight; facilitate referrals to pain specialists; increase federal support for pain management research; and develop collaboration between law enforcement and health professions to address the misuse of opioids. The epidemic has seemed to have slightly subsided in the past few years, however, thanks to the realization by physicians and lawmakers that pills were ending up on the street, and many states have thus cooperated to mitigate “painkiller tourism” by improving pharmacy monitoring.
In 2012, nationwide deaths from prescription painkillers dropped 5 percent from 2011, though at the expense of the 35 percent increase in deaths from heroin overdose (over 40 deaths per 100,000 people). Though heroin is not necessarily more addictive than OxyContin, the impurities that result from its manufacture often render it more dangerous and unpredictable. It is one of the most addictive drugs, and is notorious for contributing a greater risk to users for hepatitis B, hepatitis C, brain abscesses, hemorrhoids, AIDS and endocarditis. Opioid use has also been associated with fatal respiratory depression, as well as hyperalgesia – an increased sensitivity to pain. Regardless, those who cannot afford the cost of prescription medications or are not covered by their insurance companies are frequently pressed to seek dishonest distributors. This is magnified by the scarcity of good treatment, caused by slim Medicare reimbursements for psychologists, as well as the patient limit set by the federal government on pain physicians. Though citizens of rural areas farther removed from healthcare centers have been cited as more liable to fall victim to these unscrupulous means, the surge of heroin has even affected white middle-class suburbia – a phenomenon that law enforcement has not seen in a past dominated by indigent urban abusers.
On December 1, 2014, U.S. Senator Charles Schumer proposed a $100 million “heroin surge” to combat a sharp rise in heroin addiction and fatal overdoses that many have now dubbed an epidemic. The money is expected to help battle drug trafficking and heroin production, bolster law enforcement efforts, and coordinate intelligence-sharing and drug enforcement efforts among local, state, and federal agencies. The emergency appropriation to the federal High Intensity Drug Trafficking Area (HIDTA) program hopes to combat high-level operations that have flooded the streets with heroin. Schumer has also stated that he is fighting to secure a funding increase that would get as much possible allocated to New York State and the Capital Region, which has witnessed a particular scourge of heroin. In 2012, nearly $8000 worth of heroin was seized in Albany County – five percent of the total seized nationwide this year thus far.
Responsible pain management is necessary to combat the deleterious advent of heroin use in the United States. Huge numbers of people are suffering not only from chronic pain and opioid dependence, but from the urge to resort to heroin to control their debilitating (and expensive) pain. Regulations must be adopted that can limit opioid overmedication without barring patients from full and proper treatment. Naturally, many physicians are wary about treating chronic pain patients, for fear of the repercussions of inappropriately handling this delicate balance, and of patients either misusing prescribed drugs or scouring illicit ones. On the other hand, there are also several cases of physicians who have flagrantly abused the system by feeding the painkiller addiction: by clandestinely distributing narcotics; exchanging drugs for sexual favors; or under/overprescribing in order to maintain patient fidelity and follow-up. It is clear that a multitude of issues – political, ethical, and biological – enter into the discussion of chronic pain and pain management, and even clearer that drastic changes must be implemented in a system that has allowed such unfortunate mishap.