Most people at some time experience acute pain, such as from a fall or traffic accident. As unfortunate as these are, the discomfort often only lasts a relatively short time from a few days to a few weeks. Many pain relief options are available and appropriate for these situations and are usually not problematic. However, many people live with some degree of constant or chronic pain that lasts for many months or even indefinitely. Although some degree of pain relief is available in these situations, there’s no “free lunch,” especially with many available medications, each having their risks. Pain relief can be a “treat” when very effective, taken for a short period, and without any undesirable side effects.
Responsible primary care providers approach pain control from a multidisciplinary, graded approach. Consider a common example in which the patient has broken his/her leg in a motor vehicle accident and was initially taken to an emergency room (ER). Pain will be severe at this point, and the ER provider will likely administer an intravenous narcotic, often dilaudid or morphine. A surgeon repairs the broken bone, and the patient is released from the hospital with a prescription for narcotic pain medication, referred for physical therapy, and instructed to follow up with their primary care provider (PCP). Depending on the severity of the accident and injuries, and the timing of the PCP appointment, the patient may still be experiencing pain at the time of follow up. Thus the patient and PCP have to decide whether additional pain medication is appropriate.
The goal of pain management is to allow maximal function for the patient. The goal is never to completely eliminate all pain, which is not usually possible or desirable. In most cases, by the time of PCP follow up, narcotics are no longer necessary. Pain at this point can usually be managed with physical therapy, nonsteroidal anti-inflammatory medications (NSAIDS), or other modalities including nerve stimulators (TENS), joint injections, and so on, depending on the reason for pain.
However, there is a dark side or “trick” with many pain relief medications, especially the narcotics, that leads to tolerance, addiction, or abuse that can destroy a person’s life. Tolerance refers to a medication becoming less effective with time, requiring increasing doses for the same effect. Physical dependence refers to when the body has adapted to the presence of the pain relief medication such that withdrawal symptoms are experienced if the medication is abruptly discontinued. Addiction refers to behavioral changes resulting from the use of medications, and includes the use of medications for non-medical reasons (recreational use). Pain relief leads to increased function and quality of life; addiction leads to dysfunctional behavior, such as loss of employment, arrests, buying or selling medications, early refills and taking excessive, nonprescribed doses, or family dysfunction.
Inappropriate prescribing and use of controlled pain medications is a growing national problem. This year two events have brought both prescribers and users of controlled medications, including many used for pain relief, under much greater scrutiny. The Indiana Attorney General has increased its focus this year on providers (prescribers), pharmacies (distributors), and patients (users). One national chain pharmacy is now requiring extensive personal health information to accompany any prescription for controlled medications. If the pharmacist does not agree that the prescription is necessary, it may be denied.
Narcotics are dangerous medications. The CDC reports that abuse of prescription pain medications has skyrocketed, killing 15 million Americans in 2009, and 12 million reported using pain medications “to get high” or other nonmedical reason. Many of these situations involved the use of stolen or shared medications. Abuse and addiction are most likely to occur when medications are taken for nonmedical reasons. However, dependence and other “tricks” of narcotics can happen even when the medication is taken for a very short time, requiring medical help to safely and comfortably discontinue. Thus although sometimes necessary, both the patient and provider should work together to use the most appropriate method of pain relief for the shortest time possible. Medications should only be taken as directed. Medications should not be shared, and should be kept in a secure location. With the increased focus on curbing inappropriate prescribing and use of narcotic pain medications, many providers are now requiring monthly visits and requiring urine drug testing, as well as continued efforts to discontinue controlled medications as soon as possible.
Trick or treat? Wise patients, pharmacists, and providers will err on the side of safety. If you have been taking a controlled medication for a chronic condition, expect increased efforts to prove the medication is needed, increased visits to the provider’s office, urine drug testing, and increased requirements at the pharmacy to continue these medications. Stay safe and don’t be “tricked” by taking unnecessary pain medication.
Dr. Fleming is the Medical Director of The Jane Pauley Community Health Center (part of Community Health Network). Ideas for this column can be e-mailed to Dr. Fleming at AskDrFleming@gmail.com