Yesterday I thought I would do a little reading about pain management. Using the trusty Internet, I entered the search and found many sites about the subject. One site did more than catch my eye.
Dr. David Kessler is an American pediatrician, lawyer, and administrator (both academic and governmental). He was the Commissioner of the Food and Drug Administration from November 8, 1990 to February 28, 1997. Grief.com advertises Kessler's #1 spirituality book, his appearances on "Oprah & Friends," his reports on "American Morning" on CNN, and his extensive lecture schedule.
Dr. Kessler studied medicine at Harvard, served his residency at John Hopkins, and taught at Columbia Law School. He was awarded the Public Welfare Medal from the National Academy of Sciences in 2001. Kessler is also well known for his role in the FDA's attempt to regulate cigarettes.
With such a distinguished record, I was floored to read the information on grief.com. Let me share that information in my post today.
"When morphine and other opioid analgesics are prescribed for the management of pain, the dose is sometimes raised to be sure that pain is well-controlled 24 hours a day, 7 days a week. Opioids given to relieve pain generally do not lead to the development of dependence. As a disease, like cancer, progresses, more opioids may be needed to control the pain on a continuing basis. When prescribed on a regular basis in a dose sufficient to relieve pain, there is no empirically-based evidence that opioids lead to addiction." (David Kessler,"Dealing With Pain: Understanding Opioids," grief.com, 2011)
First of all, I understand Dr. Kessler qualifies his stance on opioids by using terms such as generally, prescribed, and sufficient. And, I know, given in proper circumstances with close management, these drugs do not lead to addiction. Society has specific needs for opioids as evidenced in the reference to certain cancer patients. The drugs must be prescribed; therein lies the potential for abuse.
However, "no evidence" negates my support of the Kessler's information on a site called grief.com. This seems irresponsible on Kessler's behalf without further warnings concerning the possibility of opioid addiction under a doctor's care. Is Dr. Kessler recommending prescription of opioids for psychological relief? I would hope not.
Brief Opioid History
About 2001-2002 Oxycontin began to openly be perceived as dangerous by clinicians and patients. Oxycontin is just a long acting preparation of oxycodone. And oxycodone is also present in more common drugs such as Percodan, Percocet, Tylox, Oxy IR.
In addition hydrocodone, which the DEA (Drug Enforcement Administration) lists as a Schedule III (meaning that refills of a prescription can be given) has seen an amazing increase. A couple of years ago 53% of all prescription opioids were one of the hydrocodones (e.g.Vicodin, Lortab, Lorcet).
Also, Methadone has seen a resurgence of usage as a long-acting analgesic that has largely supplanted Oxycontin in that capacity. Predictably there is now much more methadone available on the streets and the numbers of methadone deaths from over dosage has risen steadily. (Carl R. Sullivan, M.D., "Opioid Dependence," healthin30.com, July 20 2007)
Defining Opioid Dependence
The Fourth Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association defines opioid dependence as "repeated use of a drug of this class to the point of causing multiple problems." The definition requires "evidence of three or more problems in the same year, including tolerance, withdrawal, use of greater amounts of opiates than intended, and use despite consequences."
Patients who do not have dependence but demonstrate repeated opioid-related difficulties with the law, impaired ability to meet obligations, use in hazardous situations, or continued use despite problems can be labeled as having abuse.
Opioid dependence is characterized by extremely unpleasant withdrawal symptoms that occur if opioid use is abruptly discontinued. The withdrawal symptoms include severe dysphoria, sweating, nausea, rhinorrea, depression, severe fatigue, vomiting, and pain. Slowly reducing the intake of opioids over days and weeks will reduce or eliminate the withdrawal symptoms. (D. Doyle, G. Hanks, I Cherney, and K. Calman, eds., Oxford Textbook of Palliative Medicine 3re Ed., 2004)
The acute withdrawal phase of opioid dependence is often followed by a protracted phase of depression and insomnia that can last for months. The symptoms of opioid withdrawal can also be treated with other medications, such as clonidine, antidepressants, and benzodiazepines, but with a low efficacy (D. Hermann, E. Klages, H. Welzel, K. Mann, B. Croissant B, "Low Efficacy of Non-opioid Drugs in Opioid Withdrawal Symptoms, Addict Biol., 2005)
Who Is At High Risk For Opioid Dependence?
An opioid use disorder can develop in anyone, but at least three groups are at increased risk for dependence or misuse. (Mamikon Bozoyan M.D., "Opioid Abuse and Dependence," ArmMed Network Media, www.health.am, March 3 2009) These groups are
1. Persons with chronic pain syndromes (e.g., back, joint, and muscle disorders) who misuse their prescribed drugs,
2. Physicians, nurses, and pharmacists, primarily because of easy access to opioids. Physicians may begin use to help with sleep or to reduce stress or physical aches and pains, and then escalate doses as tolerance develops.
3. Those who buy street drugs to get high. While some of these individuals have prior histories of severe antisocial problems, most have a relatively high level of premorbid functioning. The typical person begins using opioids occasionally, often after experimenting with tobacco, then alcohol, then marijuana, and then brain depressants or stimulants. Occasional opiate use, or “chipping,” might continue for some time, and some individuals never escalate their intake to the point of developing dependence.
Increased opioid abuse coincides with a controversial U.S. campaign against undertreatment of pain that has caused an enormous increase in opioid prescriptions. Abuse of prescription opioids has grown particularly explosively during this time. The great majority of illicitly used prescription opioids are obtained from one physician, not from drug dealers. (Adrian Preda, MD, "Opioid Abuse, emedicine.medscape.com, January 11 2011)
For many, the decision to begin taking drugs is voluntary: it may have started with medicine that a doctor prescribed for serious pain, or with recreational drug use with prescription pain medications or with heroin use.
Regardless of how a person became dependent, once dependence has developed, it is considered a disease that requires treatment. And, once a person becomes addicted or dependent on a drug, he or she may find that willpower is no match for the chemical, behavioral, and psychological nature of opioid dependence.
How alarming is the fact that many health care professionals often misuse opioids? The dangers of the drugs certainly would not concern those who have developed dependence, themselves. Perhaps, this is a key to unlocking the truth about opioids -- the entire medical profession must be educated about these particular drugs and their potential for destruction. And, the entire medical profession must be held accountable for misuse of opioids. Should random drug tests be mandatory for all workers?
Once Dependent On Opioids...
Once persistent opioid use is established, severe problems are likely to develop. According to statistics from the American Medical Network, "At least 25% of habitual users die within 10 to 20 years (a mortality rate 15-fold higher than the general population) from suicide, homicide, accidents, or infectious diseases such as tuberculosis, hepatitis, or AIDS. The latter has become an epidemic among injection drug users, with an estimated 60% of these men and women carrying HIV."
Imperatives Now
Before prescribing an opioid analgesic, a professional should gather a complete history that elucidates patterns of life problems and any history of opioid use. If a problem with opioids is suspected, gathering further data from a relative or close friend can be helpful. Additionally, clinicians should search for physical stigmata of misuse (e.g., needle marks) and, when appropriate, screen blood or urine for opioids.
Dr. Kessler has not lied. I want to make that perfectly clear. Yet, with the terrible epidemic of prescription drug abuse and with the deadly results of opioid dependence, Dr. Kessler should reconsider the implications of his information.Without detailed warning, many people will interpret his words to mean opioids are safe drugs. Not that he believes that, but the general population of Americans who thrive on soundbites and bits of information could be at risk without heed. Grief.com? The true grief is suffered by those addicted to opioids and by those families that have been devastated due to opioid addiction.
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