By Linda Cheek.
As more doctors are attacked for treating chronic pain in the country, chronic pain patients are finding fewer doctors willing to provide treatment. Also, with the current non-scientifically based stance that opioids are bad, doctors are unwilling to treat appropriately. The VA, for example, proudly announces that they have decreased their opioid prescribing by 65%. James L. Sall, PhD, clinical quality program specialist at the VA Office of Quality, Safety and Value, stated “When it comes to opioids for chronic pain, just don’t do it,” (1)
Criminal prosecution of pharmacists and physicians for prescribing and dispensing opioids is being stepped up. In August, 2017, the Department of Justice announced the formation of the Opioid Fraud and Abuse Detection Unit, which will use data to pinpoint healthcare providers who prescribe opioids.
Under pressure to curb opioid prescriptions, clinicians are increasingly reluctant to prescribe them. As a result, 73% of physicians and 82% of pharmacists responding to a recent Medscape survey say that the opioid epidemic has changed their prescribing habits.(2)
With the latest government attack on Dr. Forest Tennant, MD, a renowned expert on pain management, and with the announcement by Jeff Sessions that more investigators are being hired in the DOJ to attack more doctors, how does this affect the 100 million people experiencing pain in the US?
The effect of continuous fear is increased stress. Acute stress can be explained as the “fight or flight” response. It is an innate survival mechanism—increasing heart rate, muscle tension, and blood sugar to prepare the body to either fight the tiger about to eat you, or run away. In ancient times, acute stress was an occasional occurrence. But in today’s society, it is ongoing, from the alarm clock going off in the morning, through rush hour traffic, deadlines at work, ad infinitum. Continued acute stress becomes chronic stress, and continuous fear of possibly losing one’s pain meds is a chronic stress.
Conventional medicine accepts the following results of chronic stress:
- Cardiovascular: increased heartbeat, increased blood pressure, arrhythmias, blood clots, heart disease, hardening of the arteries, heart attack, and heart failure.
- Musculoskeletal: Stiff neck and/or shoulders, increased back pain, worsening rheumatic diseases.
- Gastrointestinal: Nausea, diarrhea, peptic ulcers, gastrointestinal reflux (GERD), irritable bowel syndrome (IBS)
- Respiratory: rapid breathing, worsening asthma and chronic obstructive pulmonary disease (COPD)
- Reproductive: lower fertility, erectile dysfunction (ED), painful menstruation, increased sexual abuse
- Skin: worsening acne, psoriasis, eczema
- Psychological: anxiety, panic attacks, depression, increased worry, lack of motivation, loss of temper, inability to deal with even small problems, feeling overwhelmed, social withdrawal, lost self-worth.
- Sleep: Chronic fatigue and sleep problems
- Behavior problems: Overeating or undereating, drug or alcohol abuse, tobacco use, decreased exercise.
Over time, stress affects:
- The Immune System: stress depresses the immune system so sickness is more frequent.
- Heart disease
- Increased alcoholism and drug abuse
Disruption in sleep and chronic pain is a vicious cycle. A May, 2016 article in Medscape shows that disrupted sleep is linked to lower pain tolerance and impulsivity. Sleep loss increases pain sensitivity which interrupts sleep.
Dr. Finan: “People are losing the positive emotional stores they need to be able to cope with pain flares that are needed on a day-to-day basis, and this could result, potentially, in a clustering of the disorders that we commonly see — this triad of chronic pain, insomnia, and depression. (3)
Hormones are affected, especially the stress hormone, cortisol. Patients with severe chronic pain already have low serum cortisol levels. “These patients don’t have enough of their own cortisol to heal or to make their pain medicines work,” states Dr. Forest Tennant, MD, recently attacked by the DOJ. He believes that many deaths attributed to opioid overdose are, in fact, caused by extremely low levels of cortisol. How does this happen? Acute pain causes a stress response, and as pain becomes chronic, the response is exhausted. This depletion explains the fatigue, mood changes, and other non-pain comorbidities.
Pain catastrophizing is a maladaptive response to pain that amplifies chronic pain intensity and distress. It is a cascade of negative thoughts and emotions in response to actual or anticipated pain and is associated with amplified pain processing, greater pain intensity, and greater disability.
Pain catastrophizing has been identified as a risk factor for opioid craving and prescription opioid misuse. It relates directly to pain intensity and serves to undermine pain treatment efficacy.
Increased Use of NSAIDS
The tapering of opioids causes an increased use of nonsteroidal anti-inflammatory drugs like Tylenol, ibuprofen, naproxen and aspirin. They increase the risk of stomach bleeds, ulcers, liver and kidney damage, overdose, and even death.
Hopelessness, Despair and Death
Patients in constant fear of losing their pain meds face increased pain, hopelessness, and despair. So the last consequence of stress on chronic pain patients is death.
Death from drug overdoses has quadrupled since 1999.(4) Suicide has increased from 30,000 in 2000 to 44,000 in 2015, or a suicide every 12 minutes.(4) A report, Pain in the Nation: The Drug, Alcohol and Suicide Epidemics and the Need for a National Resilience Strategy, predicts a 60% increase in suicide by 2025 compared to the previous decade (2006 to 2015). Life expectancy in the country decreased in 2015 for the first time in 2 decades,”(5)
But patients receiving prescription opioid therapy are not the major driving force behind drug overdoses. Instead, it is the result of patients being cut off of their medication, A study of veterans published May, 2017 in JAMA Psychiatry, found that migraine and chronic back pain are associated with an elevated suicide rate. Suicide is the 10th most common cause of death in the United States. Hopelessness also plays a part in the elevated risk of suicide. “negative expectations about one’s ability to effectively manage or treat pain could lead to suicidal ideation.”
Call to Action
Former U.S. Rep. Patrick J. Kennedy says “We have all the experts who know what to do; the think that is missing is the political will to do it.” “If our legislators don’t hear from us, they do nothing.” (4) First, we must disassociate the cause/effect of opioid use with addiction. This is by understanding the REAL cause of addiction. Second, we must get the legislature to stop the illegal use of the Controlled Substance Act to attack physicians treating patients. DoctorsofCourage.org is one possible means for providers and patients to come together to work for the common good.