Physicians are trained to alleviate the pain and suffering by offering appropriate pain relieving treatment. Pain is treated with alternative therapy that includes massage therapy, physical therapy, yoga, counter irritant ointment and herbal medications. If alternative therapy fails to relieve pain, then anti-inflammatory medications are prescribed. Opioids are prescribed when alternative therapy and anti-inflammatory medications fail to relieve pain. Opioid is the most effective analgesics but also causes opioid addiction that resulted in opioid epidemics and life threatening respiratory failure.1 Physicians were reluctant to prescribed opioids until 1990 and were aware of opioid addiction, thus physicians were extremely selective about prescribing opioid for pain until 1990.2 Number of opioid users increased after 1990. In 1990 pain was considered as a 5th vital sign. Pain intensity is measured as visual analogue score from zero to ten. Zero is no pain and ten is maximum intolerable pain. Physician were asked to provide adequate pain relief to improve quality of life of patient suffering with acute and chronic pain. The physician prescription behavior was monitored by politician, medical societies and legal institution. The pain being a subjective symptom, pain score was found not reliable tool to measure pain intensity in clinical research.3,4
The opioid addiction resulting in opioid epidemics is predominantly observed in three groups of people:
- Individual Suffering with Acute Pain
- Individual Suffering with Chronic Pain
- Individual Involved in Recreational Use of Opioids
Opioid Addiction in Individuals Suffering with Acute Pain
Acute pain is caused by fracture, dislocation, injuries and surgeries. Most acute pain lasts for 3 to 6 month. Patients are given opioids for pain relief when conservative therapy and anti-inflammatory pain medications fail to relieve acute pain. Severe acute pain often needs opioid for optimum pain relief. Most patients suffering with acute pain discontinue opioids once pain subsides. But few get addicted to opioid pain medications.1 Most of these patient who become dependent on opioid suffer with decreased pain threshold and rapid development of addiction to opioids. The lower pain threshold and addiction results in higher demand for pain medications. Patient who become dependent and addicted to opioids often complaint of continuation of chronic severe pain and inadequate pain relief with any medication. Opioid addicted patient frequently visit ER, primary care physician office and pain clinics. Pain is subjective symptom described by patient and cannot be measured with any instrument. The pain intensity is measured as number zero to 10. Zero is no pain and 10 is maximum pain. Most patient who are dependent on opioid and become addicted are never able to give subjective pain score of less than nine or ten. Spouses and family members in most cases also find it difficult to see their loved one suffering with intolerable pain. Spouses and close family members demand more pain medications from treating physician. Few patients become addicted to opioid pain medications following acute pain.
Opioid Addiction in Individuals Suffering with Chronic Pain-
Chronic pain is caused by cancer, scar tissue pinching nerve following surgery, healing of fracture and dislocation. Chronic pain lasts for more than 6 months. Few patients become addicted to opioids after taking opioids continuously for chronic pain for over 6 months. Pain is a subjective symptom and intensity of pain is measured as mild, moderate, severe and very severe. Pain score is often modified to 10 by opioid addicted patient once individual gets addicted to opioid. Now, instead of asking for help to treat addiction, individual addicted to opioid start doctor shopping and opioid seeking. Physician often fail to discontinue opioid prescription. Most opioid addicted individual suffering with chronic pain often take more pain pills than prescribed and seek additional opioid pills. Continued use of higher dosage of opioid pain medication by patients suffering with chronic pain results in increased tolerance and resistance to opioid pain relief effects. Such pain is often severe and known as neuropathic pain. Most neuropathic pain do not respond to average dosage of opioids and there is always demand for higher opioid dosage to achieve pain relief. Higher opioid dosage may result in respiratory depression and death. Chronic pain is real but few individual get addicted to opioids and pain relief is never adequate because of increased resistance and tolerance to pain relief. Patient simultaneously suffer with decreased pain tolerance and often consume excessive opioid to get optimum pain relief, which often causes life threatening severe respiratory depression and failure.
Opioid Addiction: Recreational Use of Opioids
Heroine is sold over the street as a narcotics and often used as recreational drug in party and social gathering. First time heroine user after few weeks of regular use get addicted to drug. Prescription opioid drug like hydrocodone, oxycodone, morphine and dilaudid are also sold over the street as a recreational drug. First time opioid user often finds it difficult to pay for expensive heroine and prescription opioid over the street for daily consumption. Most opioid addicts are unable to pay for street heroine or synthetic opioids for continuous use. The addicted individuals then start exploring possibility of collecting prescription of opioid pills from primary care or pain physician. Large number of opioid addicts visit physician office with fictitious acute and chronic pain to get pain medication. The number of malingerers have substantially increased since 1990. In 2016, 250 million opioid prescriptions were given out to individual who were opioid drug seeking and also suffering with acute as well as chronic pain.1 Several opioid addicts and drug seekers have undergone surgeries to treat fictitious pain, so treating physician will keep prescribing opioids. Opioid addicts with fictitious pain often suffer with low pain tolerance and pain becomes real and much severe after surgery. Scar tissue following single or multiple surgeries pinches surrounding sensory nerve that follows severe and real chronic pain. The pain intensity become extremely severe because of decreased pain tolerance and increased resistance to opioid.
Certain percentage of population have a tendency to be addicted to opioid and other brain stimulating medications. The clinical and lab research suggests the reason for opioid addiction in few individuals is abnormal genetic system triggering secretion of certain hormones. The opioid epidemics is directly related to the ease of availability of street and prescription opioids. The purchasing cost of street opioid is extremely high and often most addicts are unable to pay for continuous use. Prescription opioid is paid by medical insurance provider and favored by most addicts. The future of controlling opioid epidemics depends on modification of laws that overseas and regulates pain physician as well as establishing wide spread teaching of opioid addiction and life threatening side effects. The wide spread teaching can be achieved through debates, lectures and discussion over social and news media. Opioid epidemics has resulted in opioid crisis.
- Opioid therapy in chronic pain. Ballantyne JC1., Phys Med Rehabil Clin N Am. 2015 May;26(2):201-18.
- Fallacies and phobias about addiction and pain. Lander J1., Br J Addict. 1990 Jun;85(6):803-9./li>
- How reliable is pain as the fifth vital sign? Lorenz KA1, Sherbourne CD, Shugarman LR, Rubenstein LV, Wen L, Cohen A, Goebel JR, Hagenmaier E, Simon B, Lanto A, Asch SM., J Am Board Fam Med. 2009 May-Jun;22(3):291-8.
- Measuring pain as the 5th vital sign does not improve quality of pain management. Mularski RA1, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L., J Gen Intern Med. 2006 Jun;21(6):607-12.
- Current Postoperative Pain Management Protocols Contribute to the Opioid Epidemic in the United States. Kelly MA1., Am J Orthop (Belle Mead NJ). 2015 Oct;44(10 Suppl):S5-8.