Inadequate Pain Management

It was inevitable. Everytime we get worked up about opioid abuse complaints about inadequate pain management are not far behind. Even though about two thirds of opioid abusers first get their drugs from illicit sources doctors are pressured to prescribe less opium derived pain medicine. I’ve seen this cycle at least three times since I entered the profession.  When politicians and the news media take up a medical cause the effect is virtually always ready-fire-aim.

We don’t seem to be focusing very much on alcohol abuse which is a far greater problem than opioid misuse. This misdirection is even more striking when one considers that there is no virtually therapeutic indication for alcohol consumption while strong pain medication is an essential part of medical practice. If alcohol vanished from the planet the well-being of its human inhabitants would only increase.

If opium and its congeners similarly disappeared the practice of medicine would be much more problematic. Remember, the purpose of medicine is twofold – to prevent premature disease and to relieve pain and suffering. This second purpose is greatly aided by the judicious use of drugs that relieve pain. The keyword is, of course, judicious.

Since we trust the lives of their patients to physicians it should be obvious that having a bureaucrat or politician oversee the prescribing habits of practitioners is not the way to better medical care. The article linked above may be a little too sensational for some observers, but it explains the consequence of preventing doctors from treating pain as they see best.

I was very cautious with dispensing morphine and its like. And as far as I know, I never had a patient to whom I gave the drug become addicted to it. But there were some patients who could not live a decent life without it. Caution and care must be observed by the physician who dispenses drugs with dangerous side effects, which is most of them.

Dr. Andrew Kolodny, who directs opioid research at Brandeis University’s Heller School for Social Policy and Management is quoted in the above article as saying that that prescribing opioids is no different from dispensing heroin. That’s not an argument; its an admission of ignorance or dissimulation. Perhaps I’m being unkind and his view is that of a physician who sees only the undesirable effects of powerful painkillers, but never sees their successful use. Think of the sightless practitioner who examines only one part of the medicinal pachyderm.

When I first started in the profession some of my teachers remembered when the use of heroin was legal. They said it was an effective pain reliever and a wonderful cough suppressant. Heroin is dangerous because it’s illegal. Were it not so and prepared in sterile and dose reliable forms its use would likely be indistinguishable from morphine. It is diacetylmorphine (diamorphine) and as its name implies is almost the same drug as morphine. It is still used in some countries for the relief of severe pain. The UK is one of these countries. When taken by mouth heroin is entirely converted to morphine by means of first-pass metabolism, resulting in deacetylation. When given intravenously it avoids this first-pass effect, very rapidly crossing the blood–brain barrier because of the presence of the acetyl groups, which render it much more fat soluble than morphine itself.

As with almost anything else in medicine powerful and potentially addictive drugs should be dispensed with care and good judgement. The current crisis resulting from illicit or inappropriate use of opium derivatives is mainly the result of social and psychological issues that go far beyond the usual purview of medicine. This real problem should not morph into the semi prohibition of powerful pain relief for patients who truly need morphine and its like. Life is complicated and the treatment of any medical disorder has side effects. It’s hard to find the right balance when politicians and TV personalities are screaming about a true national problem which they ascribe to the practice of medicine and yet also look to the profession for its solution.