Scope of the Opioid Epidemic:
Over the last two decades, more than 175,000 Americans have died from prescription drug overdoses. This is more than 50 times the number of people that died in the World Trade Center attacks. In this video, Dr. Aaron Kolodny discusses the rise of this epidemic and how the number of deaths has risen proportionately to the number of opiates prescribed.
Dr. Kolodny is the chief medical officer of Phoenix House which is a nonprofit addiction treatment organization. He is also the president of Physicians for Responsible Opioid Prescribing (PROP). He is the previous chair of psychiatry at Maimonides Medical Center in New York City. Here, he is speaking at a conference sponsored by PharmedOut which is a project based out of Georgetown University Medical Center. PharmedOut is a project promoting evidence-based prescribing and educating healthcare professionals about pharmaceutical marketing practices. In this video, Dr. Kolodny also discusses the roles that aggressive marketing and aggressive lobbying for opioid pharmaceuticals by multibillion-dollar pharmaceutical companies has played in the massive increase of opiates in our society.
He also discusses the evidence, or lack thereof, supporting the use of chronic opiates for chronic nonmalignant pain. The video contains multiple graphs, diagrams, and statistics that help paint a clear picture of what is occurring regarding a subject that is so controversial from a legal, social, and medical standpoint.
The current trend among many if not most pain specialists is to reduce, minimize, or eliminate opiates for the use of managing chronic nonmalignant pain. Many studies have shown only minimal benefit if any for utilizing chronic opiates for nonmalignant pain. It appears that only a small minority of patients do actually get significant improvement in pain and function. While opiates are very useful for acute pain and severe post surgical pain, their benefits seems to reduce or even disappear after several weeks. At that point, long-term opiate use may even increase the likelihood of having chronic pain. This is due to the development of centralized hyperalgesia where the body simply makes more and more pain receptors to accommodate for those occupied by the molecules of the opiate medication.
The current trend among pain specialists is to utilize non-opiate methods of pain management.
Some of these options include lifestyle changes such as increasing exercise, weight loss, and smoking cessation. Psychological interventions such as cognitive behavioral and mindfulness training therapy can also be helpful to help "rewire the brain" in order to better deal with the pain signals coming from the peripheral nerves.
Physical medicine utilizing physical therapy, myofascial release, yoga, electroceutical medicine, and chiropractic care are helpful to many people suffering from chronic pain.
Psychiatric care to address underlying or undiagnosed psychiatric disorders can help remove some of the barriers associated with optimizing function. Psychiatric care is also often helpful to help treat the depression and anxiety associated with being in chronic pain.
Interventional pain management options utilizing precision image guided injection of medication, ablation of nerves transmitting chronic pain signals, and neuromodulation of pain signals at the spinal cord level can help many of those suffering with chronic pain.
For some, neurosurgery addressing structural causes of chronic pain can help eliminate the underlying source of the pain, thereby eliminating or markedly reducing the symptoms.
For those patients who are already taking chronic opiate medication, it can be quite a challenge to reduce and eliminate the opiates. For these individuals, the care of a specialist experienced with these issues is required. For most a slow titration down and off of the opiates can accomplish the goal while minimizing withdrawal side effects. For some outpatient detox treatment utilizing a partial opiate agonist such as buprenorphine can help them accomplish the goal.
For others, particularly those taking multiple addictive medications such as opioids and benzodiazepines (Xanax, Klonopin, Ativan, Valium, etc.), inpatient treatment under the care of an addictionologist may be necessary.
Utilizing the above techniques and technology, most individuals with chronic pain can be treated without opiates while achieving similar to better results than patients with the same problem on chronic opiates.
For a small minority of patients, however, these options are either inaccessible or do not achieve the desired result. For these individuals, chronic opiate therapy may be helpful in maintaining pain control and quality of life. However, even in these cases close monitoring for adverse side effects, dependency, and addiction are necessary; often requiring the management or consult of a specialist in chronic pain management.