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The OxyContin Exam
The Problem
OxyContin (oxycodone) was originally designed for the
treatment of malignant pain such as that accompanying cancer. However,
the narcotic guidelines established by the Federation of State of
Medical Boards have not been followed. These guidelines include the
recommendations for a psychological and substance- abuse evaluations
prior to prescribing.
These guidelines also call for a consultation with,
or referral for, an examination of co-existing mental disorder such as
pre-existing depression, anxiety, sleep and other disorders.
Overlooking co-morbid psychological disorders is very
prevalent in rural South even before the emergence of OxyContin, it
and was seen with Percodan, Vicodin, and similar agents.
An organized
marketing campaign
by the manufacturer of
OxyContin
and a number of pain societies, has promoted that “pain is often
undertreated in general and that opioids are safe in most instances
and should be prescribed more often for chronic pain of all types.”
While this may be accurate for cancer or other forms of
intractable peripheral pathology, this marketing campaign was used to
justify opioid treatment for many patients with nonmalignant,
nonstructural chronic pain.
Psychological distress and chronic diffuse pain are
closely associated. As a result OxyContin has been inappropriately
prescribed for those for whom the drug was not originally designed…and
for whom it will not likely be effective…and for whom it will rapidly
result in addiction and abuse.
The vulnerable patients especially at risk for the
dangers of opioid therapy are those in rural regions where
insufficient attention is given to pain-generating and amplifying
psychosocial factors. In effect, the patients are medicated without
understanding the non-physical factors that go into their pain
complaint.
The use of opioid drugs for chronic pain focuses on
criteria such as degrees of pain (a largely subjective parameter),
rather than on etiology. The degree of pain often correlates poorly
with objective findings. This broad approach does not account for the
essential distinctions in the biological and psychological origins of
chronic pain subgroups, which are important to
understand in making informed therapeutic decisions.
The attempt to broaden the indications for opioids
has also failed to address long-term adverse consequences,
particularly of
OxyContin.
Pain clinics have formed for the primary reason of prescribing
analgesics, especially opioids, while at the same time frequently
downplaying or disregarding nonpharmacologic approaches, including
psychological testing and management necessary for a large number of
the chronic pain population.
Insufficient attention to guideline recommendations
has created the current
OxyContin
abuse,
which has grown into a major medical, social, and law enforcement
problem in many rural areas.
Pain is a complex sensation modulated by central
brain pathways, including the nerve centers and networks responsible
for emotions. The types of chronic pain for which opioids were
originally intended are caused by pathological processes in tissues or
organs from diseases such as cancer or intractable nerve or joint
damage. In these conditions, the drugs combine with opioid receptors
on nerve cell bodies in the brain and spinal cord that connect to and
attenuate the electrical activity of these afferent nerve pathways
stimulated by peripheral tissue lesions.
In other common types of chronic pain, similar
structural abnormalities in peripheral tissues are
not
present. Pain is produced and intensified by central brain mechanisms,
including emotions, which are stimulated by a spectrum of chronic
psychological distress and result in disordered central pain
regulation and amplification. The outcome is a persistent chronic
stress response characterized by dysfunctional neuroendocrine
reactivity to psychological, as well as to physical and physiological,
stressors. For this, Oxycontin was not intended.
Because opioids may have mood-elevating or altering
effects, particularly in individuals with chronic pain and psychic
distress (conscious or subconscious), these drugs may facilitate
psychological dependence by their action on central affective (mood)
nerve networks, as opposed to the peripheral afferent nerve pathways
of tissue damage or destruction in patients with malignant pain. In
essence, it appears that opioids work on different nerve pathways in
cancer than for the work-related injuries for which they are too often
prescrived. The localization of opiates in the pleasure centers of the
human brain is further evidence of the intimate relationship between
emotional states and pain processing.
The treatment of pain of central origin should focus
on attenuating the causative and perpetuating psychobiological
factors, rather than masking them with exogenous opioids. The risk of
long-term dependency or addiction by their direct effects on the
emotional component of pain while depleting the brain's natural
endogenous opioids should make opioids a
last
resort for treatment of chronic, nonmalignant pain.
Solutions
Certain medications such as low-dose tricyclic
antidepressants for improved sleep and selective serotonin reuptake
inhibitors (SSRIs) for depression and/or persistent pain are
beneficial in selected patients with fibromyalgia, and chronic low
back pain not caused by specific structural lesions. Both conditions
frequently have multiple psychosocial and cognitive variables unique
to each individual that need to be recognized and treated as part of a
multidisciplinary treatment program including self-management
techniques.
Disregarding
these factors, which are essential in the origin and amplification of
symptoms, predisposes the patient to polypharmacy, drug dependence,
and a dysfunctional state in which each symptom is medicalized.
One of the most common reasons for patient visits today
is the large range and severity of multiple unexplained symptoms,
including pain, which are associated with stressful life events,
psychological distress, depression, and anxiety disorders.
Non-surgical back pain should be viewed and managed in
this broader context, rather than as a discrete disease requiring
medications (including opioids) as principal therapy. Recognition that
a number of these patients would rather have a "physical disease" than
confront the effects of stressful past or present life circumstances
may be helpful in their overall evaluation process.
OxyContin
misuse could serve to strengthen the importance of good clinical
judgment and the need to evaluate each patient in context. This
includes determining whether chronic pain originates from peripheral
or central mechanisms, and adhering to the narcotic guidelines for
adequate psychosocial evaluation prior to prescribing opioids.
Pain should not be treated in isolation without
understanding of its roots, just as fever mandates a search for
causes. Undertreatment should refer not only to drug therapy, but also
to the absence of important nondrug interventions. The appropriate
management of chronic pain is multimodal, including nonpharmacologic
therapies, especially for pain of central origin. Diagnosis and care
should be individualized and involve other disciplines as indicated,
including clinical psychology, psychiatry, stress management, health
education, and physical and/or occupational therapy.
The “one drug fits all" orientation to chronic pain
is a risky practice with many pitfalls. More attention must be paid to
proper patient psychosocial evaluation.
based upon a published discussion by Stephen G. Gelfand, MD |
