October 03, 2014 — Blog Post
The Trouble with Pain Medication
Prescription narcotics are a controversial topic. Doctors receive pressure from both sides: they are encouraged to provide aggressive and adequate pain treatment, while also being criticized for over prescription of narcotics contributing to addiction and overdose. (1)
Prescription of narcotic pain medication has been on the rise for more than 20 years. In 2011, drug overdose was the leading cause of injury and death among 25-64 year olds, causing more deaths than motor vehicle accidents. More than half of these deaths were related to prescription drugs. (2) The vast majority of addiction and overdose are only found in chronic users or abusers. This is why many recent studies question the safety and efficacy of narcotic use for chronic pain, as these patients are at high risk for abuse, tolerance, dependence and other complications. Despite this, some patients have concerns about using narcotics appropriate for acute short-term pain management.
As an emergency physician I treat pain on a daily basis, and I see both sides. I’ve had patients with serious fractures refuse necessary pain medication due to concerns about addiction or side effects. I’ve seen other patients become very angry when they are offered Tylenol or Motrin instead of narcotics, even when narcotics would be completely inappropriate such as for treatment of a small laceration or a minor injury.
Despite the controversy on both a systemic and personal level, for the individual patient adequate pain control with narcotics can be essential to treatment after injuries or surgeries. Being able to control pain: allowing early mobility and return to function is important in preventing post-surgical complications such as deep vein thrombosis (blood clots) or pneumonia.
Adequate, safe pain control can be achieved with careful discussion between patient and physician. Talking about exactly how much pain medication should be taken, how to taper it, and when pain medication should be discontinued is essential. Especially given the confusing way prescriptions are often written: due to limitations in how prescriptions are labeled, pain prescriptions are often written in vague terms such as “1-2 pills every 4-6 hours as needed for pain,” leaving patients confused.
Additionally, we need to consider how much pain is too much? The reality is, no medication will completely alleviate all pain, the goal is to make it tolerable and allow return to function. Patients and physicians should talk about pain goals, how to achieve those and how quickly to expect pain to decrease and allow tapering of pain medication. Remember, often pain level will remain the same but the patient will find themselves doing more of their usual daily activities, and this is still an improvement in pain control.
Understanding side effects is also important: these can include constipation, somnolence, and impaired judgment. These are temporary, and when using narcotics for short-term treatment of acute or post-operative pain they can be monitored and treated. Avoiding driving, taking a few days off work while treating the pain and taking stool softeners while ensuring adequate hydration will manage most of these side effects.
Overall, fears of post-surgical addiction to opiates are generally groundless (3) and narcotic use for acute pain and post-surgical pain is accepted as safe. (4) Physicians and patients need to maintain an open dialog about pain and pain treatment to ensure safe, adequate pain control without risking long-term complications.
1. Centers for Disease Control and Prevention (CDC),. Leading Causes of Nonfatal Injury Reports [online]. cdcgov. 2002. Available at: http://www.cdc.gov/injury/wisqars/nonfatal.html. Accessed August 14, 2012.
2. Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and Reporting System (WISQARS) [Online]. 2005. Available at: www.cdc.gov/ncipc/wisqars/default.htm. Accessed August 14, 2012.
3. Carr DB, Jacox AK. Acute Pain Management: Operative or Medical Procedures and Trauma Clinical Practice Guideline. 1997.
4. Manchikanti ML. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain. 2010.