Beyond Narcotics for Effective Pain Management

An editorial by Andis Robeznieks titled “Prescription drug abuse deadlier than use of illegal drugs” in American Medical News was but one of many articles and editorials constituting the swelling backlash against abuse of prescription drugs. Age has its virtues. One of them is perspective. Having been in practice for a quarter of a century, it has been my opportunity to watch many fads come and go in medicine. Sometimes they quietly fade away—dying of inattention and loss of interest. Other times fads are truncated—a pendulum forced away from extremity by adverse outcome. The current fad of apparent narcotic leniency is an example of the second. The article by Robeznieks discussed deaths in Florida attributed to drug abuse. Specifically, he detailed that between January and June of 2002, Florida medical examiner reports listed as the cause of death cocaine in 180 deaths, benzodiazepines in 150 deaths, methadone in 133 deaths, heroin in 121 deaths, oxycodone in 112 deaths, and hydrocodone in 61 deaths. In total, prescription-type narcotics accounted for 40% of the deaths. Obviously, this is but the tip of a much larger “iceberg” of narcotic-related misuse problems. Robeznieks stated, “In 2001, the DAWN (Drug Abuse Warning Network) report estimated that 43% of the 1.1 million emergency department drug mentions were a result of abusing legal prescription or nonprescription medications.” Yet, even this is still only a part of the iceberg, since excessive use of narcotics tends not to be mentioned in patients who have a condition that might defend (but doesn’t really) the excess use of the drugs. Other data and national statistics may be obtained online. The trend is toward an increasing emphasis on excessive narcotic use by some individuals. From data of this type, both from the perspective of abuse and the growing backlash in the literature and media exposure, it may be argued that current American policy to narcotic leniency is a fad—a temporary excessive interest that reflects a momentum more than a logic. The current fad to narcotic leniency came about as the result of 2 principal factors: (1) a national recognition of pain as a real issue, requiring attention and (2) the utilities of leniency. Pain certainly is an important issue. Pain is the single most common complaint leading patients to doctors. Pain may stop function. Pain may create misery. And, we have many medications that may be helpful in the control of pain. So, pain control is an important national agenda. On the other hand, pain is not simply a discussion of physical illness (pain as nociception). Discussion of chronic pain heavily centers on issues of anguish in many patients. And, in these latter conditions, the chronic use of pain medications leads to life deterioration. This is the addiction discussion. When pain medications are used to control a “painful” experience of sensory input (nociception) then people tend to do well, and addiction is largely not an issue. When the pain source stops, the pain medication use also stops. In contrast, when pain medication is used to control anguish (emotionally “painful” experience) then the patient may be encouraged to allow the basic social/psychological problems to continue. The drugs lead to “escape,” but when the drugs wear off, the problems are still present—possibly even worse due to inattention. Using narcotics to control anguish leads to life deterioration, increasing drug dependency, reduced social capacity, and emotional dissolution. This is the problem of addiction. When patients are suffering from anguish, several mechanisms may lead the patient to the doctor with complaints of physical pain. Stress biology is a major cause of pain syndromes in patients with anguish. Chronic stress causes pain due to increased sensitivity to painful stimuli (via neural sensitization mechanisms), and stress also causes an increase in pain generators such as chronic muscle spasm or stress-induced bowel problems. Anguish also leads to somatization: fear of dysfunction and illness leading to excessive focus on health. Anguish also leads to anxiety and depressive disorders, with excessive worry or excessive pessimism. Anguish also leads to the desire for “escape.” So, to understand a patient’s pain we must understand many things. When we fail to understand that the complaint of pain is really the derivative of an anguish mechanism, then we may prescribe the very medications that propagate the problem. America is interested in good control of pain. But, good control of pain does not always mean prescribing more pain pills. This point has been underestimated in the recent fad of narcotic leniency in America. This leniency has also been promoted by another factor—utility. For a doctor, it is vastly easier to give a prescription for a pain pill than to confront the issues that make doing so unwise. When the patient says, “I have pain,” it is much easier to make the presumption that there is some nociceptor rather than to explore for anguish. In addition, in a country enamored of the concept that pain is undertreated, the pursuit of a sanguine balance may be less than popular. So, America has recently been involved in an experiment, the experiment to see what happens when restraint is removed from the use of narcotics. Not surprisingly, the result has included some adverse outcomes. These reveal that overly simplified thinking about the pain issue will not produce a universally good outcome. The pendulum is now forced back more toward center. Another fad begins to end. We will not treat pain correctly until we understand it. We will not understand pain until we understand both nociception and anguish—both represented by “pain.” In America, we will continue to have problems with narcotics until we learn that we can manage both nociception and anguish. Anyone who believes that narcotics are the problem has simply missed the point. Anguish is the problem. Narcotics are simply not a good way to manage it. Thus the flurry of articles recognizing the potentially serious outcomes of drug abuse may herald an end to another fad, the fad of excessive narcotic leniency in America. It won’t be the first time that backlash has been required to recenter an imbalanced pendulum. And, it won’t be the last.

deadlier than use of illegal drugs" in American Medical News was but one of many articles and editorials constituting the swelling backlash against abuse of prescription drugs. [1][2][3] Age has its virtues. One of them is perspective. Having been in practice for a quarter of a century, it has been my opportunity to watch many fads come and go in medicine. Sometimes they quietly fade away-dying of inattention and loss of interest. Other times fads are truncated-a pendulum forced away from extremity by adverse outcome. The current fad of apparent narcotic leniency is an example of the second.
The article by Robeznieks discussed deaths in Florida attributed to drug abuse. Specifically, he detailed that between January and June of 2002, Florida medical examiner reports listed as the cause of death cocaine in 180 deaths, benzodiazepines in 150 deaths, methadone in 133 deaths, heroin in 121 deaths, oxycodone in 112 deaths, and hydrocodone in 61 deaths. In total, prescription-type narcotics accounted for 40% of the deaths. Obviously, this is but the tip of a much larger "iceberg" of narcotic-related misuse problems. Robeznieks stated, "In 2001, the DAWN (Drug Abuse Warning Network) report estimated that 43% of the 1.1 million emergency department drug mentions were a result of abusing legal prescription or nonprescription medications." Yet, even this is still only a part of the iceberg, since excessive use of narcotics tends not to be mentioned in patients who have a condition that might defend (but doesn't really) the excess use of the drugs. Other data and national statistics may be obtained online. 4 The trend is toward an increasing emphasis on excessive narcotic use by some individuals. 5 From data of this type, both from the perspective of abuse and the growing backlash in the literature and media exposure, it may be argued that current American policy to narcotic leniency is a fad-a temporary excessive interest that reflects a momentum more than a logic. The current fad to narcotic leniency came about as the result of 2 principal factors: (1) a national recognition of pain as a real issue, requiring attention and (2) the utilities of leniency.
Pain certainly is an important issue. Pain is the single most common complaint leading patients to doctors. Pain may stop function. Pain may create misery. And, we have many medications that may be helpful in the control of pain. So, pain control is an important national agenda. On the other hand, pain is not simply a discussion of physical illness (pain as nociception). Discussion of chronic pain heavily centers on issues of anguish in many patients. And, in these latter conditions, the chronic use of pain medications leads to life deterioration. This is the addiction discussion.
When pain medications are used to control a "painful" experience of sensory input (nociception) then people tend to do well, and addiction is largely not an issue. When the pain source stops, the pain medication use also stops. In contrast, when pain medication is used to control anguish (emotionally "painful" experience) then the patient may be encouraged to allow the basic social/psychological problems to continue. The drugs lead to "escape," but when the drugs wear off, the problems are still pres-ent-possibly even worse due to inattention. Using narcotics to control anguish leads to life deterioration, increasing drug dependency, reduced social capacity, and emotional dissolution. This is the problem of addiction.
When patients are suffering from anguish, several mechanisms may lead the patient to the doctor with complaints of physical pain. Stress biology is a major cause of pain syndromes in patients with anguish. Chronic stress causes pain due to increased sensitivity to painful stimuli (via neural sensitization mechanisms), and stress also causes an increase in pain generators such as chronic muscle spasm or stress-induced bowel problems. Anguish also leads to somatization: fear of dysfunction and illness leading to excessive focus on health. Anguish also leads to anxiety and depressive disorders, with excessive worry or excessive pessimism. Anguish also leads to the desire for "escape." So, to understand a patient' s pain we must understand many things. When we fail to understand that the complaint of pain is really the derivative of an anguish mechanism, then we may prescribe the very medications that propagate the problem.
America is interested in good control of pain. But, good control of pain does not always mean prescribing more pain pills. This point has been underestimated in the recent fad of narcotic leniency in America.
This leniency has also been promoted by another factor-utility. For a doctor, it is vastly easier to give a prescription for a pain pill than to confront the issues that make doing so unwise. When the patient says, "I have pain," it is much easier to make the presumption that there is some nociceptor rather than to explore for anguish. In addition, in a country enamored of the concept that pain is undertreated, the pursuit of a sanguine balance may be less than popular.
So, America has recently been involved in an experiment, the experiment to see what happens when restraint is removed from the use of narcotics. Not surprisingly, the result has included some adverse outcomes. These reveal that overly simplified thinking about the pain issue will not produce a universally good outcome. The pendulum is now forced back more toward center. Another fad begins to end.
We will not treat pain correctly until we understand it. We will not understand pain until we understand both nociception and anguish-both represented by "pain." In America, we will continue to have problems with narcotics until we learn that we can manage both nociception and anguish. Anyone who believes that narcotics are the problem has simply missed the point. Anguish is the problem. Narcotics are simply not a good way to manage it.
Thus the flurry of articles recognizing the potentially serious outcomes of drug abuse may herald an end to another fad, the fad of excessive narcotic leniency in America. It won't be the first time that backlash has been required to recenter an imbalanced pendulum. And, it won't be the last.