Chronic Pain and the Opioid Epidemic
Chronic Pain and Pain Management in Medicine
- Pain Measurement Scale - Levels of pain: 0 (No Pain) to 10 (Worst Pain Imagineable) - 0: No Hurt - 1-2: Hurts Little Bit - 3-4: Hurts Little More to Even More Hurts - 5-6: Hurts Whole Lot - 7-8: Severe to Very Severe Pain - 9-10: Extreme Pain
Prescription Opioid Misuse Epidemic
- Overview and importance of understanding the opioid crisis in pain management.
Personal Case Study: Travis Rieder
- Background: 2019 Professor of Philosophy and Bioethics at John Hopkins University. - Rieder's Accident: - Motorcycle accident in May 2015; foot crushed. - “Limb salvage” surgery: Five operations to save his foot. - Treatment involved high doses of opioids and gabapentin for nerve pain.
Nature of Pain
- Definition and Categories: - Pain is a symptom indicating an injury or other bodily issue. - Physical Pain: Localized to the area of injury (e.g., foot). - Emotional Pain: Not localized, felt throughout. - Pain occurs in the brain; signals from injuries prompt experiences of pain. - Example: Phantom limb phenomenon exhibits how pain can occur in non-existent body parts.
Subjectivity of Pain
- Subjective Experience: - Only the individual can experience and report their pain. - No external verification possible; pain is felt uniquely. - Pain's existence is confirmed by the individual alone (epistemic access). - Pain is characterized by its phenomenology: It is constituted by how it feels qualitatively. - Types of Pain Sensations: - According to the International Association for the Study of Pain (IASP), pain is described as an “unpleasant sensory and emotional experience associated with damage.”
- Includes sensations like itching, dyspnea, pressure, and dull aches.
Assessment of Pain
- Difficulty in assessment due to its subjective nature. - Defense and Veterans Pain Rating Scale: Another scale to gauge levels of pain ranging from mild to unbearable pain. - Rieder's experience of hitting a 10 on the pain scale: - Moment where pain is maximized, nothing can be worse; describes it as a state of hell. - Raises critical question: Is one individual's 10 the same as another's 5?
Opioids: Definition and Functionality
- Opioids: - Most potent pain medications available. - Not universally effective; poor efficacy for nerve pain (contrasted with anticonvulsants like gabapentin). - Definition: - An opioid is classified by its molecular relation to the opium poppy (natural) or the human body’s opioid system. - Opiates: Derived directly from the opium poppy (e.g., morphine, codeine).
Opioid System Functions
- Functions of the opioid system include: - Blocking pain (endorphins), producing euphoria (leading to addiction). - Opioids can slow bodily systems, particularly respiration, causing potential overdose. - Physical dependence consequences include constipation and dangerous respiratory slowing.
Challenges of Opioid Prescribing
- Distinguishing between dependence, addiction, and serious pain in emergency settings. - Subjective nature of pain complicates assessment for doctors. - Dependence Risks: Individuals prescribed opioids long-term often develop physical dependence (e.g., Rieder’s case).
History of Opioids in the U.S. – The “Swinging Pendulum”
- Historical context of opioid use and regulation: - Post-Civil War recognition of opioid addiction with soldiers’ usage. - Early liberal use followed by strict regulation and eventual prohibition. - Late 19th Century: The introduction of diacetylmorphine (heroin) by Bayer, claim that it was non-addictive. - Controlled access through laws starting in 1908 leading to prescription-only availability.
Pain Advocacy and Shift in Medical Perspective
- 1970s–1980s: Movement towards seriously addressing pain treatment: - Kathleen Foley emphasized importance of pain management. - Opioids gained acceptance for cancer and end-of-life care but expanded use led to future issues. - American Pain Society proposed pain as the “fifth vital sign.” - 1996: Purdue Pharma introduced Oxycontin, claiming it was non-addictive and marketed it aggressively without solid evidence.
The Prescription Opioid Epidemic
- By the 21st century: Increased opioid dependence, rise in overdose deaths, and legal actions against Purdue Pharma for misrepresenting drug safety. - Resulting caution from physicians in prescribing, increasing black market activity for opioids.
Understanding Opioid Dependence vs. Addiction
- Physiological Dependence: Presence of withdrawal symptoms when opioids are absent, indicating physical reliance. - Withdrawal Symptoms: Include dysphoria, insomnia, restlessness, hyperalgesia, nausea, and diarrhea; opposite to drug effects. - Distinction from Addiction: - Dependence doesn't equate to addiction. One can be dependent without being addicted. - Addiction involves loss of control and harm, characterized by a habitual strong desire to use the drug.
Definition of Addiction
- Walter Sinnott-Armstrong and Hanna Pickard’s Definition: - Addiction is described as a strong habitual want reducing control, leading to harm. - Control characterized as the ability to act freely concerning desires. - Rieder aligns with this definition: - Describes addiction as a compromised ability to act due to abnormal desire connected to brain changes.
The Disease Model of Addiction
- Addressing whether addiction should be classified as a disease due to changes in brain’s motivation and control function. - Debate exists as to whether addicts have true powerlessness against their urges. - Evidence suggests addicts maintain some control over actions despite the addiction.
Summary of Addiction and Control
- Control and harm are not binary; they exist in degrees. - Addiction can compromise freedom, but other factors can also impair control.
Final Reflection
- The ongoing challenge: balancing pain management with the prevention of addiction and overdose through thoughtful prescribing practices.