Stuck on You

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Dr. Mortimer Fein joins me today in a treacly duet about opioids while we’re still both mobile enough to dance (and sing) around these sticky issues.

I’m gonna stick like glue, yay yay because “I’m stuck on you.” (gyrate hips as needed).  

Elvis’ first hit single of the 1960’s released soon after he got out of the army was his 13th number one hit single at the time. A bouncy little ditty, it knocked Theme from a Summer Place by Percy Faith out of the number one spot.  

In 1984, Lionel Richie sang,I’m stuck on you, I’ve got this feeling deep down in my soul that I just can’t lose.” It reached number 3 on the charts.

Being stuck has been a romantic notion in song – at least until the opiophobes got ahold of it and have been using it in their newest rhetoric arising from a recent study linking the duration of one’s initial opioid prescription to the likelihood of remaining treated on long-term opioid therapy – indeed when given a 10 day prescription 1/5 people will remain treated with opioids at one year. This rate is higher than for people who receive a shorter duration initial prescription. These data arise from looking at insurance claims and have almost no actual clinical information about the care of these individual patients though that doesn’t stop some from making proclamations about them as a group.

In a completely unbalanced report seen this morning on NBC’s Today Show advertising an upcoming documentary about the opioid epidemic, this statistic was reported as the likelihood that someone will become “stuck on opioids” without even the remotest attempt to suggest that some of those folks will legitimately require longer-term opioid therapy at one year, nor was there any suggestion that in all likelihood most of these patients are anything other than addicted. Requiring opioids for one year or more DOES NOT equate to addiction.  We sure would like to see the alternative peer review literature that supports that! The language is not subtle and people who use it do not even begin to entertain a single thought about how and why this might happen other than owing to the addictive power of opioid medication.

So there you have it…a 10 day exposure leads to addiction for 20% of people exposed. A statement which is, of course, ludicrous and disproven nationally on a daily basis. 

Instead of turning this new finding into a caricature, or worse, enshrining it into law and policy, it is something that deserves a whole lot of thought and understanding because of what it says about how we monitor people when they initiate opioid therapy, or as they potentially move from acute to chronic pain, or whether clinicians know how to structure and monitor therapy when they started it as an acute measure but it might be moving toward something that will be ongoing. This latter point is important, because it is never too late to put in place the goal setting, education, structure, monitoring and additional safeguards and therapies that are needed in long term opioid therapy even if the physician and patient backed into it unexpectedly.

So with all this talk about top 10 hits, what are the Top 10 alternatives to the interpretation of these data other than that people are addicted because they remain STUCK ON OPIOIDS at a year:

  1. The person was still taking opioids at one year and was judged to be deriving benefit and so the therapy was continued. The patient wasn’t stuck on opioids any more than a diabetic would be considered stuck on insulin.
  2. The doctor prescribed a longer duration prescription to the patient because they saw warning signs that they were likely to have chronic pain that was adversely affecting quality of life including inability to maintain a work schedule, related advancing anxiety, stress, and depression
  3. The doctor prescribed a longer duration prescription because he/she was already aware of the patient’s history and knew them to have chronic pain
  4. Pain severe enough to require a longer initial opioid prescription has a higher likelihood of becoming chronic than less severe pain
  5. Whether the doctor realized it or not at first, the person went on to require long-term opioid therapy for chronic pain
  6. The person had risk factors for addiction and had acute pain and these risk factors were not assessed prior to the prescription
  7. The person developed a depression or anxiety problem in the aftermath of acute injury and these were unassessed and so the patient developed dependence on their opioids because of the need to self-medicate whereas they should have been referred for mental hygiene, including counseling
  8. The patient had acute on chronic pain when opioids were initiated and the medications were continued to aide with their chronic pain
  9. Poor insurance coverage for branded non-opioid anlagesics or lack of other community resources meant that the only pain therapy available to the person was opioid therapy
  10. The person did actually develop loss of control and the myriad interventions that could have been used by the prescriber were not because the prescriber didn’t recognize the problem, specialist and addiction medicine resources and knowledge were limited or because such referrals were denied when they were initially needed and could have interrupted the trajectory

We do wish that every prescriber monitored and assessed their patients closely and when treating particularly younger people for acute injuries were mindful about carefully understanding the patient’s use of these medications and need for renewals. Such renewals should never be granted without careful thought and consideration. We don’t want to live in a world in which severe acute injuries go untreated but we also need to know if a person starts developing aberrant behaviors in the aftermath of these injuries, in the face of becoming depressed for example, and not leave them to self-medicate rather than receiving the additional services they might have needed for these problems. 

It is simply shocking how the media is no longer even paying lip service to the need for opioid pain treatment. If using scare tactics helped people treated for acute pain and made them mindful of how they are taking their medicines there might be a modicum of good that would come from this rhetoric, but instead this will simply scare people off, lead to immense suffering and rationalize poor pain treatment as we continue our downward slide back to the bad old days.  Kidney stones? Better not risk addiction. Compound fracture? Likewise. And how many with these problems might turn to unmonitored opioid use, borrowing them from friends and family out of desperation, or worse, turning to the ample supply of really scary illicit opioids now on the street. Drug dealers would be happy to fill the void if we don’t.

These findings about initial prescription and duration of therapy should be a wake-up call to the need for clinicians to monitor and be thoughtful about acute and chronic pain treatment. Instead they are being interpreted yet again as a statement of the addictive nature of opioids.

An important component that remains largely ignored is the responsibility of professional colleges to train graduating clinicians adequately and to provide overwhelming opportunities for continuing education in the pain space by experts in the field. Without this, we will likely continue to swirl around the drain of idiocy as we ignore a humanistic approach to treating pain while patients get sucked down a miserable abyss of hopelessness. 

Thank you….thank you very much.

As always, Drs. Fein and Fudin encourage comments.

 

13 thoughts on “Stuck on You

  1. Thank you , Dr. Fudin to deconstructing their argument in their anti opioid zealotry. Point by point, an excellent dissection, Doctor. Thank you. Many in the journalistic world either 1) do NOT care, and simply report by remote control and cash their check or 2) are easily fooled by the opiophobia propaganda and intentionally post these harmful ‘articles’ and lastly, unfortunately, 3) many so called ‘journalists’ or ‘doctors’ writing these types of anti opioid/addiction implication articles are intentionally, willfully spreading propaganda and disinformation to the masses for some unknown end game.
    Truth speakers, like yourself , are not too common. So I applaud your efforts..as frankly..we ARE literally “dying out here”…

  2. Dear Jeff et al,

    I have one suggestion: opiophobia is the wrong term. It implies an irrational fear. An acrophobic is afraid of heights, rather than hating tall buildings or mountains. And, an acrophobic would like to be able to go up, rather than eliminate all possibilities of going up.

    I believe an alternative couple of options exist: Mis-opiothropes or opioloathers. both suggesting the person hates rather than fears the concept of using opioids. Equi-irrational, but more pernicious than simple fear.

    1. It all began when I was 20. Involved in Multiple trauma on a motorcycle with a helmet. Car didn’t see us….. hit us mainly me. Thrown 65 feet.. 46 fractures, dead at the scene. 16 surgeries 3 years to learn how to walk. That was 40 years ago. Still have 2 A O compression plates 16 screws. At 36 years of age diagnosid with relasping remiting multiple sclerosis another chronic pain issue. Recovering from attack a year ago. Pain for me is insanity! Oh did I mention fractures L 1-L5 incuding bulging disc T-12. Subluxed S- 1.compund comminuted tibia / fibula, 50% of my femur was gone. Contused kidneys, bladder and a crushed left foot with nerve damage and foot drop. Right medial tendon replacement. Teeth shattered.
      Now I also have, torn rotator cuff to right shoulder, fuch’s corneal dystrophy, severe post traumatic pain from spinal stenosis. Sprained right medial ACL.
      Tried all the OTC’s. Vicodin helped me make through another day. Those days are gone. Tried acupuncture, PT for 3 years. TENS unit, on & on. Since there are so many “addicts” who want the high. They lumpef.me in the same category. Very sad by this.
      I suffer everyday 24 hrs a day. No doctors or pain clinics have helped sure I had epidural injections too. Worked for 24 hours.
      I exercise, stretch & try to mantain my sanity.. neurogist gives me Tramadol 50mg. What a junk med.
      I’m depressed, in pain constantly!!! But no opiods for you!!!!
      Don’t know what I’m going to do… why did i work to survive and live…

      1. pam…i dont know what to say other than i will pray for you and your grim condition…..its not often i dont have a day without pain that would make a pro football player cry like a baby…..and i too cant get relief and cut off and ostracised like you i go thru the same motions of trying to stretch and excersize etc…..its redundant and futile sometimes i think but i wont let the pain control me or run my life…..somedays are bad some are worse but no matter what i wont let it consume me….i refuse to let it keep me down……it feels like a no win situation but i do it for me and my sanity…..well im rambling but i wanted you to know that i feel for you and you will be in my thoughts and prayers…..god bless you…..

      2. Pam I don’t know what state your in and if you can get some but since my dr. Did the same to and is in the process of dropping to zero opiates. As I do not want to go on a methodone and Mary jane clinic 4 hours away from my house I am trying KRATOM. It is working not in the exact same way as a pain pill but damn near enough. Please do your research and TRY IT.

      3. Pam you are a miracle and you have been through hell and some day there will be a rainbow just for you a promise that your joy will return, But right now you need a pain management doctor that sees you pain and suffering. One that is willing to work with you and Medication that will work to give you some sense of being complete as your body is changing and trying to heal… Please don’t give up make a journal of physicians you have seen and ones that might see you with the pain you are trapped living in. Pam as I find myself bed ridden I will think of you and pray your match for a physician filled with compassion and understanding. Stay strong one day at a time…

  3. And CNN’s Van Jones uses the media bully pulpit to announce that physicians hand out jars and jars of opiates that lead people to addiction. But he fails to disclose in the same discussion that he is heavily invested in addiction treatment centers that have targeted federal funds for their growth. So, we keep on keeping on, because like the turtles, slow and steady crosses the finish line.
    And in Great Falls Montana, 1000 consumers with complex chronic pain syndromes are discharged from their pain management clinic into the abyss because…opioids…

  4. i haven’t seen any improvement in media coverage–but i hope i’ve just missed it. every time i read, hear or see how many deaths per hour are attributable to opioids i’d like the corresponding statistics for alcohol and tobacco presented simultaneously. maybe a crackdown on the prescribers and recipients of those drugs should …oh, wait. never mind.

  5. I actually think that the media has gotten better over the past year, albeit marginally. They’re still clueless, and their irresponsible reporting indirectly causes bizarre amounts of human suffering.

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