Limiting use of prescription painkillers has become a major public health goal in the United States in large part because these drugs now cause more overdose deaths than cocaine and heroin combined. (1,2) Much of this effort focuses on persuading physicians to limit the frequency and the amount of their prescriptions. This makes great sense, of course, but it neglects the fact that many, perhaps most, people addicted to prescription painkillers live with terrible pain. Yes, doctors should prescribe more carefully; but they should also do a better job of helping their patients to eliminate, reduce, or tolerate pain that otherwise can make life unbearable.
Seems obvious, doesn’t it? Maybe. But it wasn’t obvious to me when I wrote about the problem of addiction to prescription painkillers last year (3,4) and apparently it’s not obvious to the Centers for Disease Control, which have a number of alarming posts on their web site about controlling access to these drugs, but I could not find any posts about the pain management.
I first became clear about the importance of improving pain management after I published an article on The Huffington Post called “Prescription Painkillers: When Are They Too Much of a Good Thing?” In this article, I, and my co-author, identified eight signs that you may be addicted to or otherwise abusing prescription painkillers. Well over 100 people responded—a very large number for that kind of article. A few thanked us or said they wished they had known what to look for before they became addicted. But most criticized—even excoriated—us. Of these, some were clearly addicts in denial. But most were people who told us we couldn’t possibly understand how much pain they live with. They knew they were addicted; but, they said, without painkillers they couldn’t stand up, couldn’t work, couldn’t feed themselves let alone their families, couldn’t think clearly, couldn’t engage in social conversation, couldn’t go out for some fun. These people believed, and they may have been right, that they needed painkillers to have a life.
Ironically, at about the same time that I heard from so many people living with terrible pain, the minor, annoying pain I had been living with became severe and disrupted my life. I could not drive without great pain. I couldn’t sit for more than a short time, making working on a computer and socializing, extremely difficult. The distances I could walk became shorter and shorter. Teaching for two hours at a time became almost impossible. Meetings with colleagues, going out to dinner with friends became more than I could bear without taking a prescription painkiller. Because I was afraid, I would become addicted, I lived with as much pain as I could tolerate and withdrew from some activities instead of using the medication I feared.
My search for a health care professional who could help me became central to my life. Over two years I saw numerous health care professionals including primary care physicians, orthopedists, neurologists, pain management specialists, an acupuncturist, two osteopaths, a physical therapist, and who knows how many radiologists. The pain got worse and worse as did my life, until I got lucky. An MRI revealed a large tumor inside my spinal column. We had identified a cause and a treatment for my pain.
Not everyone is so lucky. One day while waiting to see a doctor at a highly regarded pain clinic, I chatted with a woman who appeared to be exceedingly anxious and depressed. She told me she was “at the end of her rope” (Think of the literal meaning of that expression). She was, she said, addicted to opiates, which she began to take after an automobile accident that broke several bones, including vertebrae in her back, and left her immobile for months. Now she could walk—slowly—and could get out for medical appointments; but, she said, she would not be able to get out of the bed in the morning without the painkillers. Even with them she was not able to work because the pain filled her mind, making it impossible to stay focused. She was also taking an anti-depressant and sometimes Xanax to quell her sense of dread when it became overwhelming. She was hoping that this pain clinic would find a way to treat her pain without opiates. Then she would go into rehab, she said, to get clean. I could see the emotional toll that unrelieved pain had taken on her. I marveled that she still had hope.
Yes, it is true that some people take prescription painkillers to get high, but a great many people who become addicted are just trying to live with pain. Modern medicine has a long way to go to help them.
The problem of pain has not gone unnoticed, of course. In fact, the Affordable Care Act (aka Obamacare) required the Institute of Medicine to do a study about pain and its treatment. The results were reported in 2011(5) and were quite startling. Over 100 million Americans suffer from “chronic” pain, according to the report. That’s one in three Americans.
I found this very hard to believe at first, but when I thought about the number of people with chronic or recurrent back problems, arthritis, neuropathic pain in their feet, etc. and when I thought about the number of ads on TV for over-the-counter painkillers, it began to seem plausible that one in three people live with pain.
Not, however, the kind, the intensity, or frequency of pain for which opiates are (or seem to be) necessary. Over the counter painkillers, non-steroid anti-inflammatory drugs (NSAIDs), steroids, anti-depressants, and other medications can relieve pain for some people some of the time. Stretching and exercise can also relieve pain. People in pain and their physicians should try these before opiates. When they jump to opiates too quickly or in excessive amounts, addiction is a real and unnecessary risk.
So, yes too many prescription painkillers are used when alternatives may work. And, yes, physicians need to be far more cautious about prescribing them. But physicians also need to take pain seriously and learn how to help their patients to deal with it.
This general truth may be all the more important in the treatment of people with serious mental illness who are, one has to believe, more likely to be living with pain than people without serious mental illness.
Why? Because they are more likely to have histories of physical trauma, more likely to be victims of violent crime, more likely to have severe physical illnesses, and more likely not to have adequate healthcare.
In addition, there is some evidence that primary care physicians are more likely to prescribe opiates for pain for people with serious mental illness than for people who are not mentally ill. (6)
So, it may be that people with serious mental illness are somewhat more likely than others to be addicted to opiates, not to get high, but to deal with terrible physical pain.
It’s distressing, it seems to me, that this is not a common topic of conversation in discussions of co-occurring mental and substance use disorders. We talk frequently about self-medication to cope with emotional distress; but I have almost never heard talk about people with serious mental illness becoming addicted to opiates because they suffer from severe physical pain.
I am convinced that addressing physical pain is critical for many people who have a serious mental illness, but I am also convinced that addressing physical pain more effectively is critical to effectively deal with the growing problem of addiction to, and overdose deaths from, prescription painkillers. Just blaming doctors for poor prescribing practices will not bring about the kind of change that is necessary to reduce the abuse of these drugs, which can be a savior or much too much of a good thing.
Michael B. Friedman retired in 2010. At the time, he was Director of The Center for Mental Health Policy, Advocacy, and Education of the Mental Health Association of New York City. Currently, he is Adjunct Associate Professor at Columbia University School of Social Work. He can be reached at firstname.lastname@example.org.
- Centers for Disease Control. “Prescription Painkiller Overdoses at Epidemic Level”. November 1, 2011.
- CDC. “Vital Signs: Overdoses of Prescription Opiod Pain Relievers: United States 1999-2008” in Weekly Mortality and Morbidity Report, November 4, 2011.
- Friedman, M. “Prescription Painkillers: Protect Yourself and Your Family”. The Huffington Post. January 31, 2012
- Friedman, M and Langosch D. “Prescription Painkillers: When Are They Too Much of A Good Thing?” Huffington Post, March 1, 2012
- Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. National Academies Press. 2011
- Seal, K. et al. “Association of Mental Health Disorders with Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan”. Journal of the American Medical Association. March 7, 2012.