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Treating Pain in the Midst of an Opioid Epidemic

Tina Levrant-Delgado has dealt with chronic pain for six years. What started as cramping in her calves progressed to her forearms, back, and into her neck. She's received numerous diagnoses, including compartment syndrome, fibromyalgia, and sciatica.
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Tina Levrant-Delgado has dealt with chronic pain for six years.

What started as cramping in her calves progressed to her forearms, back, and into her neck.

She's received numerous diagnoses, including compartment syndrome, fibromyalgia, and sciatica.

"I am always in pain, it's just a matter of how much," Levrant-Delgado told Healthline. "When you see me, I look perfectly healthy and happy, so I've just learned to act the part. I don't like to bore people with my pain levels."

Levrant-Delgado is one of the estimated 1.5 billion people worldwide living with chronic pain.

She was prescribed topiramate (Topamax), an anticonvulsant drug. She stopped taking it after having an adverse reaction.

Instead, she manages her conditions through diet, exercise, reflexology, and bimonthly full-body massages. She also takes herbal supplements.

"As they aren't as strong, they aren't 100 percent effective, but at least I don't feel 'stupid' when taking them," she said.

That "stupid" feeling is a major attraction for prescription painkillers.

While they can help mitigate serious pain, chronic and widespread abuse has created a severe drug epidemic.

Opioid drug overdoses quadrupled over 15 years, with 16,000 people dying in 2013, according to the latest estimates from the U.S. Centers for Disease Control and Prevention (CDC).

As the United States copes with these cases of severe addiction, the medical community is taking a closer look at prescribing practices, pain management training, pill mills, and how pain is treated.

The Rise of the Opioid Epidemic

Sales of opioid drugs, including morphine, codeine, hydrocodone, and oxycodone, nearly quadrupled from 1999 to 2010.

Deaths during this time increased at the same level, accounting for more deaths than heroin, cocaine, and benzodiazepines combined.

Last year alone, more than 170 million prescriptions for opioids were filled in the United States.

Opioid addiction has been described as the worst drug epidemic in U.S. history, and it's a common pathway to heroin. Nearly half of all heroin users report being addicted to prescription painkillers.

The latest numbers from the CDC show 46 Americans die every day from an overdose of prescription painkillers.

For each death caused by overdose, there are 32 emergency room visits, 130 people who either abuse or are dependent on painkillers, and 825 nonmedical users. One survey found that six of the top 10 abused substances by high school seniors were pharmaceuticals.

"The people having the serious adverse events are at a young, prime productive age," Dr. Asokumar Buvanendran, professor of anesthesiology and pain medicine at the Rush University Medical Center in Chicago and member of the American Society of Anesthesiologists, says. "I think that needs to be put into curtailing this."

Pain vs. Pleasure

A key driver in the epidemic, the CDC says, is the rate prescription painkillers are prescribed.
In fact, 259 million prescriptions were handed out in 2012, which roughly equates to one bottle for every adult living in America.

While abuse grows, prescription painkillers are still a founding block of chronic pain management.

Pain specialists and medical professionals stand at a crossroads between treating patients with legitimate medical conditions and those seeking the drugs for pleasure. This has created a paranoia-like phenomenon for many doctors.

Dr. Conrad F. Cean, a pain specialist with six offices in the New York City metropolitan area, says the growing trend of prescription drug abuse is making it difficult for physicians to treat chronic pain patients for fear of sanctions to their licenses.

"Pain physicians are now routinely declining to accept patients on relatively high-dose narcotics to avoid being flagged," he told Healthline. "This leaves some challenged in finding providers to help their pain."

James Giordano, a neuroscientist and chief of the neuroethics studies program at Georgetown University, says there are two faults at play.

The first is an over-sensitive clinician who prescribes medications to keep a patient satisfied. The second is a clinician who doctrinally refuses to prescribe painkillers.

Giordano says these two approaches are wrong, but for Dr. Joseph Pergolizzi, an adjunct assistant professor at Johns Hopkins University School of Medicine and chair of the Association of Chronic Pain Patients, the central issue remains helping to ease his patients' pain.

"The main goal we need to think about first is the patient and the pain they are experiencing," he told Healthline. "As a doctor, I'm treating individual patients. I'm not treating society."

Those treating society's pains aren't always pain specialists. According to Giordano, 20 percent of chronic pain cases are treated solely by family practitioners.

"Chronic pain management is just that, management. It's not mitigated by a single doctor's visit once every three weeks," Giordano says.

Eliminating Pill Mills

In the 1990s, laws regarding opioid painkiller prescriptions became more liberal, which resulted in an upswing of prescription rates.

From 1997 to 2007, the United States saw a 402 percent increase in the average sales of opioids per person. During that time period, retail sales increased 280 percent for hydrocodone, 319 percent for hydromorphone, and 866 percent for oxycodone.

Since then, deaths related to these drugs have continued and state and federal lawmakers have changed policies to reduce prescriptions and deaths.

States that have enacted programs aimed at lowering prescription rates have found success in lowering potentially fatal overdoses. These programs include requiring prescribers to check state databases before issuing prescriptions and preventing doctors from dispensing painkillers from their offices.

In 2012, the state of New York required prescribers to check a state database to prevent doctor shopping, resulting in a 75 percent decrease in patients seeking the same drug from multiple doctors. A similar measure in Tennessee saw a 36 percent drop, according to the CDC.

Drug enforcement agencies have also started cracking down on large-scale pill mills, or what Florida's attorney general defines as any healthcare provider that conspires to routinely prescribe pharmaceutical drugs outside the scope of medicine.

Florida was one state with lax pain management laws: 98 of the top 100 oxycodone dispensing doctors in 2010 were practicing in Florida.

After implementing federal drug raids and stronger pain management regulations, the number of registered pain management clinics in Florida dropped by more than 500 in the past four years, from 900 to 367. This large-scale crackdown decreased the number of oxycodone overdose deaths in Florida by 50 percent in 2012.

Most states have some form of a prescription drug-monitoring program to curb abuse. For example, the Illinois Prescription Monitoring Program allows pharmacists to access a database that collects patient prescription information of all highly guarded medications, such as painkillers stronger than acetaminophen (Tylenol).

But Buvanendran says state-monitoring programs should be federalized because high-risk patients can travel to nearby states that don't have such databases.

"It needs to be linked with all the states," he says. "It's not like this is a small, rare problem. There needs to be more resources to stop the epidemic."

Doctor Shopping and Secondary Users

Nowadays, doctors and prescribers are increasingly aware if a patient exhibits drug-seeking behavior.

"In a sense, it's very tough for a doctor because we don't have proof they're going to sell it or someone is going to get into their medicine cabinet, so it becomes a problem," Pergolizzi said.

A major hurdle in slowing prescription drug abuse is keeping them out of the reach of those who aren't using them for pain. This is a difficult task since nearly half of prescription opioid abusers are getting them from friends or relatives.

These "secondary users" make up a major part of opioid deaths. Experts say these users first try opioids not to treat a medical condition, but to test out the drugs' euphoric high.

Still, doctors continue to prescribe opioid drugs for those at the highest risk of overdose -- those who abuse prescription opioids 200 or more times a year. Research shows these patients get their pills through their own prescriptions 27 percent of the time.

Dr. Anna Lembke, an assistant professor of psychopharmacology at Stanford University, argues that doctors prescribe opioids to high-risk patients partially because treating pain has financial incentives while treating addiction does not.

"Countless patients come to emergency departments and doctors' offices throughout the country every day reporting pain and receiving opioids despite known or suspected addiction," she writes in the New England Journal of Medicine.

States in the South have some of the highest prescription rates in the country.

From 2007 to 2011, one-third of Tennessee's population filled an opioid prescription each year according to a study featured in the Journal of the American Medical Association.

Nearly 8 percent of people in Tennessee who died from a prescription drug overdose in 2011 used four or more doctors to get their prescriptions. Using multiple prescribers or pharmacies accounted for more than half of the state's 1,059 overdose deaths in 2010.

The Education Gap

The opioid epidemic is a problem that needs to be tackled from several angles.

Many experts believe it can start with better pain management education for doctors, something that currently is lacking at the majority of medical schools.

Current research on the effectiveness of pain treatment curriculum in medical schools shows the curriculum doesn't meet the needs of physicians, patients, and society.

"Unfortunately pain management and the different types of pain is not as completely or thoroughly stressed during the four years of med school that many, including myself, believe it should be," Giordano says. "For the general physician, you don't necessarily get the breadth or depth of pain management training that might be necessary."

Eighty percent of American medical schools require one or more pain management courses as part of general required courses, compared to 92 percent of Canadian medical schools.

According to a 2011 study, "Pain education for North American medical students is limited, variable, and often fragmentary. There is a need for innovative approaches and better integration of pain topics into medical school curricula."

Research has shown that just one educational session can have lasting impact on how students view treating pain. A 1992 study found that first-year medical students enrolled in a six-hour course on the behavioral, social, and biological aspects of pain "reported more accurate estimates of the frequency of problems with addiction stemming from acute pain treatment and exaggerated the prevalence of pain problems in the society" up to five months after the course.

Earlier this month, the U.S. Food and Drug Administration's (FDA) panel recommended that doctors who prescribe painkillers, especially opioid painkillers, undergo specialized training. It was the second time since 2010 the panel advised expanding safety measures for painkillers, according to The New York Times.

There's also legislation before the Senate to create an inter-department task force to address best practices for treating chronic pain with opioid painkillers.

Also, legislation has been introduced into Congress that would require a similar FDA panel to review any opioid painkiller without abuse-deterrent properties.

It's known as the Opioid Review Modernization Act of 2016, and, according to, a non-government website that tracks bills, it has a 47 percent chance of being enacted into law.

Examining Other Pain Relief

Although some doctors feel their options for treating chronic pain are limited without opioids, there are other alternatives.

Physical therapy or similar types of effective treatments are always possibilities, even though experts point out that patients are less inclined to pay for these because they are expensive and results are not immediate.

An alternative for the treatment of surgical pain is to prescribe anesthesia before a major surgery, says Dr. Kevin Stone, an orthopedic surgeon at the Stone Clinic and the founder of the Stone Research Foundation in San Francisco.

He says that because narcotics inhibit muscle formation and slow metabolism, they make healing after major surgeries even more difficult. Using pre-emptive anesthesia instead can numb a joint for up to two days after surgery so the patient feels less severe pain.

"Narcotics have a very limited role in what we do," Stone says. "There are more long-acting anesthetics that are coming out that make surgical pain nearly a nonissue."

Another option, which Pergolizzi believes will soon be more readily available, is abuse-deterrent compounds. These drugs counter the dependence problem often associated with opioids.

They may also be more advantageous for long-term use, especially since experts say using opioids for long periods of time can actually cause users to become more sensitive to pain.

Future research on treating chronic pain is also in the works.

The National Institutes of Health BRAIN Initiative, a $4.5 billion research project, is looking to find viable targets for drugs, including low-tech approaches.

Still in its nascent stage, the BRAIN initiative hasn't led to pharmaceutical interventions just yet, but one area of focus is on cellular and circular targets (i.e., those directed at only certain parts of the brain, like pain centers and others affected by brain disorders).

"What we're finding from the brain science is that pain management is a multifocal practice that demands a multidisciplinary approach to its execution," Giordano says.

Medicinal Marijuana Finds New Patients

Besides opioids, medical marijuana has also seen a spike in usage.

This is mainly due to relaxed drug enforcement laws, including 24 states that have legalized cannabis for medical or recreational use.

According to some estimates, the legal U.S. marijuana industry could reach $35 billion by 2020.
Dustin Sulak, founder of the medical marijuana practice Integr8 Health in Maine, says 70 percent of the patients he sees are for pain, mainly back pain. Half of his new patients are already taking opioids and use medical marijuana as a combination therapy aimed at helping them reduce their opioid intake.

"Cannabis helps pain differently than other treatments," he said. "It changes the interpretation of pain. It gives patients a chance to work through the pain."

Rebecca Holley, founder of Therapy in a Bottle, a hemp and cannabis treatment manufacturer, said that despite loosened regulation, many patients don't pursue medical cannabis in fear of repercussion.

Considering the Drug Enforcement Administration still rates cannabis as a Schedule 1 drug, research into its usefulness as a painkiller has been dampened by heavy guidelines and regulation.

"A lot of people are deterred from even trying cannabis even if they have a terminal illness and it is their last resort," Holley said. "Even in states where it is legal to use cannabis medicinally, patients are still at risk of being fired from their jobs or not being able to get one because of such strict and archaic testing guidelines."

Compared to the addiction and deaths associated with prescription painkillers, medicinal cannabis may become a more mainstream, long-term pain reliever.

"Cannabis is not fatally addictive," Holley said. "The addiction is not associated with the actual plant and its chemicals, rather, its associated with the benefits that the plant's chemicals provide."

Overall, experts agree that research, education, monitoring, and varying treatment options are the best course of action to prevent further addiction and death.

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