Pain Podium

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You may recall my recent Pain Pod three-episode series “Opioidology”, which attempts to not only add the needed granular bandwidth of all aspects of our opioid crisis beyond the simplified overlap of the healthcare and illegal drug supply chains (emphasis on those being two distinct entities). The first episode attempted an investigative reporting approach to all aspects, including the extremes and everything in between, in respect to the logistics, postulates, and compassion of the millions of lives lost to substance related deaths over the years.  The second episode pivoted to a clinician perspective on how to select the most appropriate prescription opioid for a patient in pain with great respect to the individual characteristics and preferences of any patient in pain. The third episode had two authors (James Hackworth and Jim Potenziano) join us to further discuss the opioid crisis considering their recent Frontiers in Pain Research article “The Burden of Acute Pain in the U.S. in the Wake of the Opioid Crisis”. My Pain Pod guests James and Jim (along with the rest of the authors) substantiated five main points within the article including rising pain prevalence, opiophobia vs opiophilia, economic impact, novel medications, and balanced guidelines. In this “Pain Podium” editorial, I will discuss the important highlights of that article and the overall opioid crisis. 

An American dies every 6 minutes from a drug overdose (and countless non-fatal overdoses), every 4 minutes from an alcohol-related death, and every minute from a nicotine-related death. Think about those staggering numbers in respect to the unfortunate lost heartbeats. Moms, Dads, Daughters, Sons, Uncles, Aunts, Neighbors, Friends, Professionals, you name it, lost lives, with rippling effects reverberating throughout our society. Yet there is often a blurred line of pain, substance use disorder (addiction), and substance use. Not every respective lost heartbeat involved someone with addiction, albeit many, many times it does, yet substance use itself and in its infancy in someone’s life can cause deadly harm. On top of that, we as healthcare professionals seem to practice in a world of extremes, opiophilia vs opiophobia, with barely anyone reasonably balancing somewhere in the middle.

Acute pain cases have surged due to increased surgeries, an aging population, and metabolic diseases such as obesity and diabetes. In other words, we made it to the moon, invented the internet, are figuring out artificial intelligence, yet have not figured out pain even to the point where it’s getting worse for so many more people. In fact, pain is reported in about 80% of ED visits with a median rating of 8-out-of-10. When coupled with the sheer reality that not many, if any, people ever actually want to visit an ED, yet when making the decision to go, it typically is pain that pushes one over the decision line in the sand. Of note, 8-out-of-10 pain is generally classified as “severe”, typically ripe for treatment with, you guessed it, a prescription opioid. Yet, how easily and often are those medications (said to the tune of “those people”) offered? The seventh of never comes to mind. Drawing from a personal experience in an Urgent Care for a rather intense and diffuse case of poison ivy (contact dermatitis) while “drug seeking” a corticosteroid, I couldn’t help but notice a sign plastered on the wall in front of anyone on the scale, “No pain medications are prescribed in this clinic”. Urgent care, urgent pain, no mas. The same sign was hovering over a urinal. Almost made me thankful for my most annoying full body itching as compared to having to endure an episode of acute on chronic pain, or even acute severe pain from an accident. I not only walked out with a prescribed steroid, yet quite the perspective. Unfortunately, patients in pain have experiences involving this extreme frame of mind daily. Conversely, pill mills aren’t exactly great for society, so every man, woman, and child doesn’t need a prescription opioid for a papercut either. Yet not treating pain can be as inhumane as overtreatment, particularly considering that acute pain can transition to chronic pain rather easily, along with centralization for an amplified and incredibly unpleasant experience. In fact, the risk of developing chronic pain from acute pain is two to three times greater in cases where severe pain is ineffectively treated in first few days. In other words, pain sucks, we need to address it, or it’ll somehow suck even worse, yet when we address it, let’s be balanced for safety and efficacy.

For whatever reason, most detective work involves following the dollar. Estimates on the cost of acute and chronic pain in our country have been climbing to almost a trillion dollars. For context, similar to DEA seizures of illegal drugs stating to be enough to kill every American (despite not accounting for the logistics of getting said drugs to every American, something that Cartels specialize in), that staggering cost figure amounts to about 3 billion (with a B) dollars per American. Almost too hard to believe, yet certainly not too good to be true. If that’s not enough, opioid misuse and overdose add double down by adding more than a trillion dollars in societal costs, for a grand total of more than 7-times what it cost to first step foot on the moon. It doesn’t seem like our society is progressing in this accord.

Concurrently, there is an urgent need for pain medications with the efficacy of opioids, yet lacking the severe side effects (respiratory depression, addiction, withdrawal, etc.) or even the moderate side effects (constipation, hypogonadism, nausea/vomiting, sedation, and so on); along with balanced clinical guidelines emphasizing safe and efficacious pain relief and improved function. I not so fondly recall a time that I was prescribed and utilized a prescription opioid for an acute outburst of visceral pain stemming from a large kidney stone (7mm, just like the bullet). During the pandemic, I was ever so lucky as to have grown a kidney stone landing me in the ER on Friday the 13th, 2020 at the beginning of the 3-year adventure anyone reading this experienced. Since the eventual removal surgery was deemed non-elective yet non-emergent, a few days later the stone shifted and about floored me in pain. I ingest one of the prescribed acetaminophen/codeine tablets as directed, and about 15 minutes later, the pain subsided and was replaced by an interesting feeling of euphoria, being that I had not yet eaten that day and was not about to wait for a snack to hit my duodenum before addressing my pain. I immediately realized what folks feel when utilizing an opioid in a different manner, and respected that experience, deciding to not end up in that scenario again, for on that day, my decision was to compassionately appreciate that I could now truly understand what would draw one to continued use despite negative consequences (a DSM-V SUD symptom), although I thought I did in the past. Apparently, I was like most people prescribed an opioid (7-of-8) who do no misuse said opioid, yet 1-of-8 people do, relatively minimal, yet when extrapolated to a population, the concern is evident. The point is, ultimately folks are faced with decisions and scenarios that are unique and appreciable, and in those moments, one’s genetics and environmental experience (even down to one’s mood on any given one day) come into play for deciding how to proceed regardless of previous risk assessments and screenings. We as healthcare professionals need to do our due diligence but given that the vast majority of drug overdose deaths stem from illegal substances, there’s only so much we can do.

There remains a lot of work ahead, a thought provoking a headache in and of itself, hopefully with an appropriate treatment available. After all, if migraines can have the incredible CGRP medications, why can’t the rest of us in pain have our cake and eat it too???