Every day, Amy returns home from work with severe aches. The pain in her back and legs is hardly bearable. She has finished an eight-hour shift and has taken the gradually increasing pain for as long as she can manage. Fighting back tears, she enters her home, goes to her bedroom, opens a small bottle and empties two Percocet pills into her hand.
Amy is one of about 100 million Americans who suffer from chronic pain. For nearly twenty years, the only relief she has gotten from day to day comes in the form of Percocet, also known as Oxycodone, a pill that was prescribed 30 million times in the United States in 2013 alone. Amy began only taking one Percocet per day, but after an unsuccessful surgery, needed to increase her dosage to two pills per day. “It is sort of a necessary thing for me to make my way through life as a functioning human being,” Amy comments.
Since the 1990s, opioids such as Percocet, OxyContin, and Vicodin have been the default treatment for Americans who suffer from chronic pain. It’s easy to see why, as millions of people rely on these opioids to alleviate pain and keep them stable throughout the day. But in the last few years, the death toll across the country from painkiller overdoses has exploded. With 28,000 deaths, over 300,000 emergency room visits for abuse, 2.5 million addictions, and 259 million prescriptions annually, policymakers cannot ignore the problem. Within the last few years, officials at both state and national levels have worked to pass new laws in an attempt to halt the ever-increasing rate of overdoses in the United States.
In Amy’s home state of Massachusetts, a law was passed in March 2016 that places several new restrictions and regulations on opioid use and prescription. Dr. Scott Weiner, an Emergency Room Physician at Brigham and Women’s hospital in Boston, expressed mixed feelings about the law, but believes that it is “making us as clinicians talk about this issue and be much more aware of the severity of the problems associated with opioids, and that in itself is helping.” One major stipulation of the law requires closer monitoring of prescriptions in order to avoid patients getting pills from multiple providers. Twenty-eight other states have enacted similar regulations, as “doctor shopping” is becoming more frequent for patients who desire more painkillers than they are prescribed. Other parts of the law change training guidelines for medical professionals to administer opioids, add opioid addiction information to school curricula, and limit how many pills can be prescribed to patients for the first time—similar limitations have been enacted in four other states.
While these regulations on opioid prescription may be effective at preventing people from becoming addicted to painkillers, two other major problems remain. Firstly, what effect will this law have on people who are already addicted? Secondly, what if the law goes too far, and adversely harms people like Amy, who are not addicted, but dependent on these opioid prescriptions? Will they be unable to renew their prescriptions under the new law?
For current addicts, a worst case scenario would be a further increase in a closely related public health crisis: heroin. “My concerns about the law, which hopefully future policy will help improve is that it might inadvertently be driving more people to heroin,” Weiner commented. Given that heroin offers the same pain-relieving effects of prescription opioids, the two problems are inextricably linked. If FDA approved opioids become harder to get ahold of, Weiner fears that many more patients will turn to heroin.
So what better solutions are there for addicts, which could be a goal of future legislation? Currently at Brigham and Women’s Hospital, if a patient comes into the emergency room, having overdoses on drugs, the medical professionals have trouble finding an available bed for the patient at a detox center. Other parts of the country, Weiner says, have a clearinghouse-type system that keeps track of what beds are available, and how to efficiently place new patients in those beds. “Another thing we’re working on … is making a bridge clinic, meaning if a patient comes in with an overdose, we can tell them, ‘On Monday morning you can come in and we’re going to get you started on suboxone, and then we’ll follow you for the next couple of weeks, couple of months, while you get stabilized on medication assisted treatment, and then after that we’ll get you to a detox and you can go to a long term program.’” Weiner commented. “Policies like that are going to be incredibly efficacious, but will need time to work.”
Weiner expressed concern about how chronic pain patients like Amy may suffer. “I see a lot of pushback from patients who do have chronic pain issues,” Weiner remarked, “They’re frankly very frightened because a lot of them are relying on these medications to function, and I think it’s becoming more difficult to get prescriptions.”
Due to heightened awareness and impending restrictions, Amy decided last year that she would do whatever she could to try to wean herself off of pain medications. She underwent surgery, and then began various physical therapy programs. After a recent targeted physical therapy session, Amy was able to go a full day without taking Percocet for the first time in eight months.
While she has hope for this new therapy, Amy still is dependent on Percocet for the foreseeable future. She said she could not imagine herself ever turning to illegal drugs, but does not know how she would handle a situation in which she no longer had access to Percocet. “I can sit here on my couch, in the comfort of my home right now, and say I would never [seek out drugs illegally],” Amy said. “But who knows what people do, if they’re in agony? … I’ve never been in that position. I’ve never had a doctor say, ‘Sorry I won’t prescribe it’ … It’ll be terrifying if I get to a point where my pain is still really bad, but my doctor is saying, we can’t prescribe this anymore … I don’t know what happens to somebody like that.”
We have to be aware of the pendulum effect; opioid abuse is a massive public health crisis that must be combated, but so must chronic pain, and we cannot allow our solution to one crisis to exacerbate another. “There used to be incredible pressure to prescribe and treat pain aggressively,” Weiner explained, “Now there’s incredible pressure to decrease our utilization of these medications. So people that have been on them for a long time, now their clinicians are being encouraged to help taper them or wean them off the medicines. And even though that might be the right thing to do, I think people are frightened by that, because they might be stable on a certain dose of medication for a long time.”
“There’s still stigma attached to this too,” Weiner added, explaining that there has recently been “a lot of scrutiny from pharmacy on opioids … That puts chronic pain patients in a precarious situation.”
Amy has noticed the stigma not just from clinicians, but from peers as well. While she is trying her hardest to eventually move away from Percocet, she emphasizes that there is nothing inherently wrong with being on painkillers. “Nobody looks twice at you if you take Advil or Tylenol,” Amy noted. “But if you say you have to take a Percocet, the room basically comes to a stop, and people immediately make a judgment.” Opioid addiction absolutely needs to be addressed, as one of the most pressing public health crises facing this country. However, millions of people like Amy, who rely on these medications and take them only as prescribed and needed, should not be ostracized for taking care of themselves. Painkillers will have a place in society for a long time to come, and the problems of treating chronic pain, preventing addiction from happening, and breaking patients out of addiction will require informed policy and measured regulations.