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Nicole Gregory: When pain kills
August 19, 2013
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CALIFORNIA: In July, the Centres for Disease Control and Prevention made a startling announcement: “Women are dying from prescription painkiller overdoses at rates never seen before.” That was followed by a number of staggering statistics, including this one: From 1999 to 2010, there was a 400 per cent increase in these deaths among women.

Four hundred per cent?

“It’s a tsunami,” said Dr C. Philip O’Carroll, programme director for the neurobehavioural medicine programme at Hoag Neurosciences Institute in Newport Beach, California.

“It’s actually an epidemic,” said Peter R. Przekop, director of the pain management programme at the Betty Ford Centre in Rancho Mirage, California.

If this increase in deaths among women was related to breast cancer, women would be marching in the streets. But the causes of painkiller overdoses among women are complex and the responsibility for the deaths is shared. (In contrast, painkiller overdose deaths increased by 265 per cent among men during the same time frame.)

“In general, middle-aged women are at higher risk than younger women for prescription painkiller overdose death,” said Dr Karin Mack, science officer of the CDC’s Injury Centre and one of the authors of the report. “Women in this age group may be more likely than younger ages to have chronic pain conditions. Also a greater daily dose is associated with a higher risk and as women age with pain, dosages may increase.”

Chronic pain — from migraine headaches, irritable bowel syndrome and fibromyalgia — can pose a challenge to doctors because physical pain is wrapped up with emotional pain.

Points to ponder

Women aged 45 to 54 have the highest risk of dying from a prescription painkiller overdose (opioid or narcotic pain relievers including Vicodin, OxyContin, Opana and methadone).

More than five times as many women died from prescription painkiller overdoses in 2010 as in 1999.

For every woman who dies of a prescription painkiller overdose, 30 go to the emergency room for painkiller misuse or abuse.

Since 2007, more women have died from drug overdoses than from motor vehicle traffic injuries, and in 2010, four times as many died as a result of drug overdose as were victims of homicide.
Shocking findings

“A study I’ve done shows that 80 to 90 per cent of patients who convert from acute to chronic pain have experienced a lot of present stress and have a history of some type of abuse — physical abuse, emotional abuse or even a bad accident,” said Przekop, who is director of the Pediatric Chronic Pain and Headache Clinic at Loma Linda University Children’s Hospital. “I think that sets them up for chronic stress. The same problem causes casual users of drugs to become drug abusers. There is an inability of those people to manage negative emotions that are associated with stressful events. And the ability to experience things they enjoy really gets broken.”

Chronic pain leads to a sense of hopelessness, Przekop said. “They can feel like everything is going from bad to catastrophic.”

Donna Mroz, an alcohol and substance abuse counselor in the Anaheim-Fullerton, California, area, agrees. “A lot of women who are in domestic violence situations feel stuck. They can’t get out, so they check out with drugs,” she said, adding that about 70 per cent of the recovering female drug abusers she works with were sexually molested “but never dealt with it.”

Fibromyalgia, a condition with symptoms of widespread pain and extreme skin tenderness that is almost exclusively a disorder suffered by women, is called a “functional disorder” because there are no objective markers for it, such as a blood test. “It doesn’t conform to the usual rules of disease,” O’Carroll said. “When you’re dealing with a terminal patient in the hospital, or an older person with painful shingles, it’s clear what to do. But when the person sitting in front of you is complaining of chronic daily head or back pain, or TMJ, it can be a crushing dilemma.”

Don’t let it go unnoticed

Signs of trouble in someone you love

•    She gets her prescription refilled before it’s necessary.
•    She visits many different doctors (“doctor shopping”).
•    She makes excuses for “lost” painkiller medication, such as it was stolen or it fell into the toilet.
•    She keeps painkillers after the initial condition has cleared up.
A seemingly quick fix is opioids — which initially appear to wash away the physical and emotional pain. “It reaches the James Brown part of the brain,” O’Carroll said. “It makes you feel good.”

But for patients with addictive tendencies, that’s where the deadly spiral can begin.

“A lot of times painkillers are prescribed by a doctor who does not realise the complexity of what’s going on with a patient, who may be depressed, anxious, have a history of traumatic events, impulsivity,” Przekop said. “Many people don’t have resilience or coping ability. They have an internal feeling that things aren’t right, and these are huge risk factors for developing chronic pain and substance abuse disorders.”

Addictive behaviour

Once hooked on painkillers, an addicted patient will quickly learn how to circumvent the rules — doctor shopping or make excuses why she needs her prescription filled sooner than scheduled.

It wasn’t always so easy to get these drugs.

“Prior to the 1980s, no doctor would use opioids,” O’Carroll said. The fear of giving patients something they could become addicted to kept doctors from prescribing opioids, to the point where some doctors were penalised for withholding them in extreme cases.

Common prescription opioids include Vicodin, OxyContin, Opana and methadone. Deaths occur because these narcotics affect the part of the brain stem that controls the respiratory system — causing a person to stop breathing. Or the painkillers are mixed with other medications or alcohol, or the patient has tried to detox and then has gone back to take a too-high amount of the drug.

Beginning in 1996, however, the thinking shifted. With a promotional push from pharmaceutical companies and New York pain care specialist Dr Russell Portenoy, who advocated the use of opiates for chronic pain sufferers, “the message went out that opiates are fine,” O’Carroll said.

“They said that there was less than 1 per cent chance of getting addicted. Now we’re finally waking up,” he said. “That 1 per cent is fantasy. We’re seeing 16,000 opioid deaths every year nationally.”

In 2007, pharmaceutical company Purdue Frederick pleaded guilty to the felony of “misbranding a drug with the intent to defraud or mislead” by claiming that its drug, OxyContin, was less addictive than other pain medication. “They were fined $634 million, but that was a slap on the wrist,” O’Carroll said.

Monitoring urged

The CDC is alerting the public and professionals to the risks and urging doctors to monitor their patients’ use of painkillers.

“Before I prescribe one opioid, I will use the patient activity report” or PAR, O’Carroll said. PAR is part of a huge database that can be used to find out if a patient has been doctor shopping.

Groups such as the American Pain Society and the American Society of Interventional Pain Physicians endorse urine testing for patients who may be at risk of becoming addicted, and some doctors insist that high-risk patients sign an agreement to use the painkillers responsibly.

Still, addicted patients who really want these drugs will find them. So what are the alternatives?

Przekop teaches patients at the Betty Ford Centre how to cope with stress, and how to do meditative movement that “gives them a chance to do an exercise, to feel OK about being in the present and get to a quiet state of mind.” He also stresses the benefits of joining pain support groups to find others who share similar experiences. O’Carroll recommends cognitive behaviour therapy and physical exercise.

As for dealing with pharmaceutical companies, doctors and patients need to be wary of the marketing.

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