Michael Connelly, MD
Nothing is more basic in medicine than the desire to treat pain, but major change is needed in how prescription pain medications are managed, and this topic is increasingly in the news.
To address these needed changes, the Massachusetts Board of Registration in Medicine now requires doctors to earn education credits on prescribing opioid medication. And the Massachusetts Legislature recently considered mandating physicians to check patient information in a prescription database before prescribing pain medication. But how did we get to this point?
During the 1990s, there was a strong effort to improve pain treatment. Hospitals were directed to record pain as the fifth vital sign, and the specialty of pain medicine grew through fellowship training programs that resulted in many doctors becoming board-certified pain specialists.
For the most part, this has been good news. We are better at treating pain during child birth and after surgery, and we now have excellent options for managing spinal pain. For example, a 10-minute procedure to place steroid medication on a painful nerve is effective for nearly two thirds of patients with a disc herniation.
But medicine made a wrong turn in the effort to treat pain by promoting more prescriptions for addictive opioid medication. This wrong turn resulted from the honest interest to improve pain treatment, combined with pharmaceutical companies promoting medications like Oxycontin.
An opioid is a medication that relieves pain by stimulating receptors in the brain and spinal cord that interfere with the transmission of pain signals. We are learning that there is a big difference between short-term pain, from a broken bone, for example, and ongoing chronic pain. Chronic pain is not well managed with opioid medication. Studies show pain continues with a very small reduction in pain scores.
A pain medication like Percocet not only turns down the pain signal, it also releases a chemical called dopamine deep in the brain. Dopamine causes us to feel good and this "feel good" response is the same response the body gets from heroin — the most addicting of opioids. Other highly addictive chemicals such as cocaine and nicotine cause a similar release of dopamine.
Though addiction is rare with short-term use, in the long term it can pose a major problem. After the release of dopamine, the brain creates more receptors for dopamine to enhance the response, and over time this may lead to addiction. Without the opioid, the dopamine receptors are empty, and empty dopamine receptors make us feel bad. The state of addiction is one where the opioid is taken just to feel normal. Without it, people feel they cannot function.
Death from prescription drug abuse — nearly 30,000 per year — is the second leading cause of accidental death in the United States. More people die from prescription drug abuse than from cocaine and heroin combined. The rapid increase has followed the increase in opioid prescriptions.
What can be done for chronic pain? The best approach is to seek a board certified pain specialist who evaluates patients for structural problems and looks more broadly at muscular conditioning, weight and stress. Treatment may involve injections, medications, physical rehabilitation, relaxation strategies for stress and medication for depression. There are limited roles for opioid medication, but based on the extent of abuse and number of deaths, a change is needed from current practice. We need more information to identify when it can be safe and effective.
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Michael Connelly, MD, a board-certified pain specialist with New England Neurological Associates, is on staff at Merrimack Valley Hospital, a Steward family hospital. The Gazette regularly publishes columns by Merrimack Valley Hospital doctors.