I just read a study published in
March of this year comparing the effect of opioid and non-opioid treatments for
patients with chronic back pain and hip/knee osteoarthritis pain. In the group
treated with opioids, included treatments were immediate-release morphine,
oxycodone, or hydrocodone/acetaminophen. In the non-opioid group, treatments
involved acetaminophen or NSAIDs. The study found that over a period of 12
months opioid therapy was no better than non-opioid therapy in improving
pain-related function, but did lead to an increase in adverse side effects.
Pain intensity was slightly lower in non opioid-treated patients.
This
article caught my interest because a lot of states have tightened their opioid
laws recently in an attempt to combat the widespread opioid abuse the United
States is currently in the midst of, which is responsible for thousands of
deaths a year among other issues. As anyone who has worked in a clinical
setting no doubt knows, the use of opioids in the treatment of chronic musculoskeletal
pain is a relatively standard approach. Many of the doctors I’ve worked with
through the changeover have struggled with how to continue treating patients
with chronic pain. Many are poorly equipped to handle treating addiction and do
not have much in the way of alternative options, at least in family practice
settings. At some point there is uncertainty about how much of a patient’s pain
is chronic and how much is coming from the opioid use itself. The most recent
guidelines now discourage use of opioids for chronic pain because there is not
sufficient evidence for benefits that outweigh the potential serious harm they
can cause.
The recent guidelines to discourage use of opioids for chronic pain is one step to reducing the opioid epidemic, but many times the situations are not clear cut. An article published by the New York Times detailed re-educating medical students on how to handle situations of addiction discusses incorporating addiction training into the curriculum for professional health students could be a solution of treating the opioid epidemic. The reason I say that is in the article it presents that blaming the patient loses their trust in the medical community which I believe would cause a more extensive problem than what we have at hand. The fear of coming to the doctors because they might be judged or even reported involves hidden implications like losing housing or their kids and could lead to them not coming in for treatment when it is urgent. As a healthcare provider, non- maleficence is important when looking at what to do for the patient. We don't want to continue prescribing and allowing them to have their prescription for a certain drug if it is leading to a addiction, but asking them to come in and talk to understand more of the patients situation can help provide them with options where a drug isn't always needed.
ReplyDeleteIf you haven't already seen it, I highly recommend a Netflix documentary called Dr. Feelgood. It discusses the practices of Dr. Hurwitz, a pain specialist who was sentenced to 25 years in prison after prescribing an absurd amount of opioids to his patients, two of which died from an opioid overdose. I was shocked that after receiving prison time, Dr. Hurwitz still stood by his clinical decisions, stating that he would do would do whatever it took to keep his patients out of pain (aka just keep increasing the dose). I do think this reveals an interesting internal conflict that we as future providers must be cognizant of. It is very difficult to say no to a patient sitting in your office in severe pain. I think the opioid epidemic is partially a result of providers wanting to help their patients but unfortunately doing the opposite. Hopefully, there will soon be better alternatives to chronic pain management.
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