USA Today recently published an article about seniors and prescription drugs, with input from Dr. Mel Pohl and Dr. Andrew Kolodny to support the claims made in their opinion piece. (See: Seniors and Prescription Drugs: As Misuse Rises, So Does the Toll http://www.usatoday.com/story/news/nation/2014/05/20/seniors-addiction-prescription-drugs-painkillers/9277489/ ) Having read the article, I am left with several unanswered questions. I am herein addressing them to you, Dr. Pohl and Dr. Kolodny.
In the video, the statement is made “We didn’t know what addiction was” but you never define addiction – nor for that matter, do you ever acknowledge how addiction differs from dependency, or even from drug abuse. Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. The disease of addiction is a chronic condition that, without treatment, is progressive and can result in lifelong disability or death. The evidence from recent research on this is growing daily, and so is the evidence that treating chronic pain patients based on this information is increasing the success rates—success rates that you also fail to acknowledge.
Drug dependency, on the other hand, is reversible. Anyone can expect to become physically dependent on a drug they take for a long time; including, for example, diabetic medication, anti-anxiety drugs, sleeping pills, nasal sprays, beta blockers and other cardiac drugs, and many OTC drugs that are NOT prescription medications. Withdrawal from dependency can be severe, but when it is over it is over. In contrast, the disease of addiction is a chronic condition that, without treatment, is progressive and can result in lifelong disability or death.
Drug abuse describes behavior born of bad decision-making; not the disease of addiction. Almost all addicts have been physically dependent on drugs, but vastly fewer people who find themselves “physically dependent” on drugs (i.e. pain patients) are addicts. When assessing your data on seniors who survived their youthful drug excesses in the 60’s, for example, did you consider this?
Also, did you consider that these same seniors know how to obtain street drugs and will do so if the option of pain control is removed? Are you willing to share the responsibility of leaving your patients no choice but to engage in criminal behavior? Are you unable to acknowledge the reality that there are expert and courageous physicians who are willing to engage in the time-consuming (and, in the media fabricated maelstrom of opioid hysteria, even dangerous) battle for suffering patients against chronic pain? Will you ever acknowledge their successes? Why do you bombastically lump all these conditions under the most alarming category of addiction?
Thoughtful physicians are taught to begin with the lowest dose, monitor their patients, and increase the dosage only as objective and subjective findings justify the increase. Why then, Doctor Kolodny, have you begun your treatment of this issue at the highest possible dosage of inflammatory rhetoric? Don’t you understand that each patient differs in their perception of pain, in their tolerance for pain, and in their response to medication and treatment?
And finally, you object to prescription opioid pain treatment but support the use of Tylenol (i.e. Acetaminophen) in patients with severe chronic pain. Have you read the research on what acetaminophen does to the human liver? Doctor, have YOU ever experienced severe chronic pain with only acetaminophen for treatment?
The flaws and gaps in your ivory tower presentation are glaringly obvious. You have failed to convince me that the best prevention for addiction is to never prescribe these drugs. In some pain-free utopia that approach might work. But we live, suffer, and die in the real world. Neither you, nor I, nor anyone will ever establish heaven on earth by banning pain drugs.
Why not treat this problem like you are supposed to treat pain. Let’s start with a remedy that has the greatest potential for benefit with the least amount of risk:
Let’s educate ourselves about the proper use of these medications, the best treatments for pain, and the value of lifestyle optimization.
Perhaps my suggestion also sounds like a utopian prescription. I am not naïve enough to believe you can eradicate abuse and addiction merely by educating the populous. But it’s a better primary treatment for our drug problem than surgically removing all access to opioid pain care. And 116 million chronic pain patients would not have to choose whether to suffer or become criminals.
Note: I have shamelessly borrowed from the published research on this subject. The information is out there.
Chronic Pain Management with Opioids in Patients with Past or Current Substance Abuse Problems. Journal of Pharmacy Practice. 2003, 16;4:291-308.