Take My Pain Away

[NRSKarenRN, BSN, RN]

Take My Pain Away

A Pain Management Physician's Perspective of Prescription Opioids and Pain Management

By Gerald Aronoff, MD, Medical Director, Carolina Pain Associates

Like the beating metronome in the music video, the title and refrain of Take My Pain Away, by rock band Moullinex, remind me of what I see each day in my pain management practice. Take my pain away,” patients have asked me for over 30 years now. Most of them come to me because they are in debilitating pain that interferes with every aspect of their lives—family, work, and community—and have been unable to find help for their pain. Hearing Take my pain away” is all too familiar to me.

Even when physicians and patients find the right treatment, if that treatment includes an opioid, getting prescriptions filled can be frustratingly difficult, as it has been for Emily. Emily is a forty-year old nurse who has suffered for years with progressive rheumatoid arthritis. Her puffy, deformed joints make ordinary tasks like brushing her teeth or walking to the kitchen to make breakfast each morning excruciating ordeals. Her story isn't unique. Chronic pain is a major public health problem in the United States that imposes an enormous burden on individuals, families, employers, and society as a whole. It affects about 100 million adults every year and, according to the Medical Expenditure Panel Survey (MEPS), costs the economy between $560 and $635 billion annually in health care costs and lower worker productivity.¹ Much of the productivity loss is in the form of lowered performance while employees are at work—because they're working in pain, unable to perform to their usual standard.² ...

...Opioids come from poppies and play an important role in pain and mood regulation. They are classified as opioids” because they act on the opioid receptor of the brain's reward system. This biochemical pathway has been conserved for millions of years through evolutionary biology to support critical survival skills like eating, social interaction, and reproduction. The body itself produces three opioids—enkephalins, dynorphins, and beta-endorphin—that give us feelings of pleasure from specific activities. These natural, or endogenous, opioids help block pain and negative emotions, enabling us to act even when we're injured or struggling with an extremely stressful situation.³ Our bodies' opioids can reduce discomfort, but they are not produced in large enough quantities to block extreme pain—nor do they have the potential to cause an overdose.⁴

The Pain Management Puzzle

Each case coming to a pain medicine practice is a puzzle that requires understanding pathophysiology, pain generators, factors that activate and perpetuate the pain, possible complicating psychosocial and environmental factors, risk factors for use of controlled substances, and concurrent medical and psychological issues that may complicate pain treatment. Chronic pain creates a vicious cycle. Pain makes people less able to continue their normal activities and, eventually, if untreated, pain can ruin their lives. They get depressed, and the more depressed they get, the more they focus on their pain. Many of these people were well-adjusted at home and at work, but their chronic, untreated pain not only affects them, it also affects their kids, their family, and their whole support system. Today, we know that physical and psychological symptoms make each other more potent. Pain can make a patient depressed, and depression leads to more physical pain....

...To unravel this complexity, in our practice, we take a three-dimensional look at the patient, using a bio-psychosocial approach to evaluating chronic pain. A comprehensive initial history is followed by a good physical exam, which, in combination with lab evaluations, clarifies not only the medical and structural problems but also the psychosocial problems that pain is imposing on the patient's daily life. We do a urine drug screen, and we look at current and past history of smoking, problems with alcohol or drugs in the patient or family, and psychological stressors, all of which can be risk factors for using controlled substances like opioids. Other factors that increase risk include a history of childhood sexual abuse and major psychiatric disorders, especially at times when they are not well controlled.⁶ So, we stratify for minimal, moderate, or severe risk, based upon the pioneering work of clinical psychologist Steven Passik and doctors Douglas Gourlay and Howard Heit—both addiction medicine specialists—and others who have examined and written on assessment, universal precautions, substance abuse, diversion, and the interface of pain and addiction....

...There is also hope that technology will help address pharmaceutical abuse and diversion. Opioids with abuse-deterrent properties are just coming into the market with formulations that become inactivated or resist being powdered or liquefied. Most of these new drugs cannot prevent abuse, but they will make certain forms of abuse much more difficult.

Among other abuse-deterrent technologies are formulations that add aversive agents, such as niacin, that cause undesirable side effects like burning or stinging when they are snorted or injected, or opioid antagonists that block the opioid receptors in the brain. Combining these advances with extended-release formulations holds the promise for achieving a therapeutic effect at much lower doses over longer periods, preventing the rush that addicts crave. Of course, none of these technologies comes without challenges. Abuse resistant and deterrent drugs have a higher price tag—an ongoing challenge in an era focused on reducing costs. I hope that healthcare plans and pharmacies will offer these newer, safer alternatives, and I hope that physicians will embrace these additional choices, rather than decide to leave opioid prescribing to far too few experts.

[AJJKRN]

With having my start on a surgical-trauma floor, I know the values and challenges of controlling acute and chronic pain. Thank you for always finding such interesting reads!

[NRSKarenRN, BSN, RN]

Your welcome!