Opioid Crisis and Increased Number of Opioid Prescription
Opioid crisis is caused by increased number of death resulting from side effects of opioid consumption. Opioid crisis goes hand in hand with increased number of opioid prescription. The number of death of opioid drug user has been increasing every year as number of individual consuming opioid has also increased. Opioid is prescribed for acute and chronic pain. Increased number of opioid prescription were given after 1990. The increased number of opioid prescription is also linked to increased number opioid addiction. Number of individuals between age 11 and 30 were misusing the opioids.1 The study published suggests prescription opioid misuse were found to be increasing since 1990.1 Prescription opioids were sold as a recreational drug and eventually resulted in opioid epidemics as well as opioid crisis. Opioid users are exposed to life threatening side effects of opioids when opioid is consumed in large dosage. The data published suggests in 2015, drug overdoses caused 52,404 deaths in USA. Out of 52,404 deaths 33,091 (63.1%) individual died from opioid overdose.2
The number is expected to increase every year. Such a large number of instant death is not observed among individual addicted to smoking tobacco or marijuana or alcohol. Chronic smoking causes oral or lung cancer, while alcohol abuse causes cirrhosis. Opioid addiction is observed among patients who are taking opioid for real chronic pain as well as individuals who have tried opioid as a recreational drug. The published reports from addiction clinic suggests individuals who have tried heroin or cocaine as recreational drug get addicted to opioid. The worst thing about opioid addiction is withdrawal symptoms, which is often troublesome and observed in opioid addict as well as individual dependent on opioid for pain relief. Most opioid addicts take opioid for craving of opioid and also to prevent opioid withdrawal symptoms. Demand for opioid prescription was substantially increased since 1990.
Pain Recognized as a 5th Vital Sign
Number of opioid prescriptions given were increased since 1990. Pain was recognized as a 5th vital sign.3 Prior to 1990 most physicians were careful in prescribing opioids for cancer patient and post-operative pain. The demand for prescription of adequate opioids dosage to relieve chronic pain increased after 1990. Several research published data between 1985 and 1990 suggesting that cancer pain and post-operative pain were inadequately treated in hospital, ER and doctor’s clinic. Pain and inadequate pain relief became subject of academic and political debate.
Visual Analogue Pain Score (VAS)
Acute and chronic pain was measured across imaginary numbers 0 to 10 known as visual analogue score (VAS).4 The number zero was considered no pain and ten as unbearable severe pain. VAS pain score was more of a subjective measure of pain symptoms. VAS, has helped to assess the intensity of pain in patient who are genuinely suffering with pain and not addicted to opioid. Several research studies were performed to evaluate the validity of VAS in patient suffering with real cancer or chronic pain. The patient selected for studies in most cases were suffering with real pain caused by cancer, post-surgery pain, fracture or joint dislocation. Most studies published were performed by university faculties who were least exposed to opioid drug seekers and malingerers. None of the published study had included opioid addict or opioid drug seekers. Few patients suffering with genuine pain but dependent on opioid to prevent withdrawal symptoms were afraid to give lower number VAS in spite of having lower VAS score because of fear of not getting adequate opioid pills. Symptoms of opioid dependent were observed in few patients suffering with genuine pain because of need to take opioids to prevent withdrawal symptoms. Such behavior resulted in increased need of opioid prescription despite lower pain score. VAS being score of subjective complaint of pain was not reliable to diagnose opioid addiction or opioid malingering.
Pain Hypersensitivity and Opioid Resistance
Few patients suffering with cancer pain or multiple back surgery often indicate signs of opioid induced hypersensitivity to pain known as hyperalgesia or neuropathic pain.5 Opioids in most cases are ineffective to relieve hypersensitive pain. Patients suffering with hypersensitive pain often demand higher dosage of opioids. Similarly, few patients suffering with chronic real pain were also showing signs of opioid resistance resulting in least pain relief.6 VAS of patient suffering with pain hypersensitivity (hyperalgesia) and opioid resistance was always found as high as 8 to 10. Higher dosage of opioids are frequently prescribed to achieve higher level of pain relief despite most patients showing signs of side effects like drowsiness and sleepiness. Margin of safety in these patients were extremely low and life threatening complication like respiratory failure were frequently observed.
Adjuvant Therapy in Addition to Opioid Therapy
Patients suffering with chronic pain and consistently complaining of inadequate pain relief often complain of symptoms of muscle spasm, anxiety and depressions. Patients suffering with these symptoms are referred to specialist like Physical Medicine Specialist and Psychiatrist. Most of these symptoms are treated with adjuvant medications, which often causes severe drowsiness and sleepiness. The side effects of sleepiness narrows margin of safety of dosage of opioids. Opioids may cause respiratory failure and death when prescribed with adjuvant medications. The demand for treatment of associated symptoms of muscle spasm, anxiety and depression is often a high priority when diagnosis is presented to patient and relatives. The opioid addicted individuals also become dependent on these adjuvant medications in spite of suffering with side effects. Drug seekers also insist on suffering with these symptoms to get adjuvant medications, which has very high street value.
Demand to Achieve Adequate Pain Relief
The adequate pain relief was demanded by politician, lawyers and close family members after 1990 when pain was considered as 5th vital sign.5 The medical associations of primary care physician, pain specialist and oncologist set an opioid therapy guideline, which was suggesting optimum dosage of opioid should be prescribed for optimum pain relief. Patients were discharged from hospital only when VAS score was zero to 2. Hospital discharge guidelines were closely followed by nurses and physicians. The opioid dosages were periodically increased by cancer and pain specialist to achieve VAS of zero to 2, while treating acute and chronic pain in clinic.
Physician Under Pressure To Achieve Optimum Pain Relief
Physicians were under pressure to prescribe higher dosage of opioids to achieve optimum pain relief. Physician were carefully increasing opioid dosage depending on VAS score of pain relief. Opioid is known to cause dose dependent side effects like nausea, vomiting, constipation, drowsiness, sleepiness and respiratory failure. The side effects like drowsiness, sleepiness and respiratory failure is observed at higher dosage. Most patients suffering with real chronic pain, and opioid addict drug seekers were demanding higher dosage of opioids by describing higher VAS of pain and denying presence of any side effects. Physicians were held responsible for inadequate pain relief supported by documentation of higher VAS and absence of side effects. Physicians were unaware of drug seekers, opioid addicts malingering pain and chronic pain patients depending on taking frequent higher dosage of opioids to prevent withdrawal symptoms. Most physicians were periodically increasing opioid dosage depending on VAS score and history of absence of side effects o achieve optimum pain relief and avoid disciplinary action by local, state and federal regulators.
Opioid Drug Seeker and Doctor Shopping
The VAS score of subjective pain symptom was manipulated by drug seeker and opioid addict. Large number opioid prescriptions were collected by opioid drug seekers, while visiting multiple physician offices for chronic pain.7 Malingering drug seekers were doctor shopping and complaining of inadequate pain relief to demand higher dosage of pain medications for inadequate pain relief. The opioids were diverted and sold for profit over street or shared with friends and families. Patients malingering symptoms of pain for opioids and complaining of inadequate pain relief were unknowingly supported by local politicians, relatives and legal councils. Physicians were prescribing opioids for chronic pain depending on subjective pain symptoms that was supported by abnormal finding in radiological studies or ultrasound. Most drug seekers, opioid addict and opioid dependent had some abnormal findings in radiological or ultrasound studies.
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