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The politics of pain; As opioid use surges, experts urge cautious approach

An average of four people in the South Hilo District died per year from opioid pain-reliever overdoses in the past decade.

In all, 94 people on Hawaii Island died of such overdoses between 2006 and 2015, according to data provided by the Hawaii Department of Health in response to a request from the Tribune-Herald.

Addiction and death from prescription opioids is a problem that a recent Associated Press and Center for Public Integrity investigative report blames on drug company-funded advocacy organizations and drugmakers. Lax controls because of their efforts and, as a result, greater access to opioids, led many who got prescriptions for legitimate pain to eventually get addicted, the AP reported.

The drugmakers and drug company-funded organizations, the AP says, “spent more than $880 million nationwide on lobbying and campaign contributions from 2006 through 2015 — more than 200 times what those advocating for stricter policies spent.”

What’s appropriate pain control? What options, other than prescription opioids, should patients and their health providers consider? What red flags should you and your family be aware of?

Dr. Kurt Halverson, a chiropractic orthopedist at Hilo Pain Clinic, said it’s essential to identify the underlying source of a patient’s pain. That’s at least half the battle, and “if we know what’s causing your pain, then we know how to deal with it.”

For example, he said, his colleague, Dr. John L. Turner, a pain specialist and board-certified neurosurgeon, is one of just a few physicians statewide using diagnostic ultrasound.

“Dr. Turner can do a nerve block in the shoulder. He’s able to provide patients with long-term pain relief,” Halverson said.

There are many options that do not involve opioids, area pain specialists agree.

Noninvasive pain management can include massage therapy, acupuncture, exercise, behavior modification, biofeedback, heating the affected area, joint mobilization and electromuscular stimulation.

Turner said pain treatment should use a progressive process, from least-invasive options such as massage therapy to pain patches and anti-inflammatory medications, and then, if pain isn’t controlled, perhaps hydrocodone and/or surgery. But opioids like that carry risk, which is why it’s important to approach pain control from a philosophy of least-intervention-first.

“I explain to the patient that, after three days, we can detect brain cells dropping out,” Turner said. “We try to use these things short term.”

It’s rare, he said, for him to prescribe opioids such as Percocet, Vicodin, hydrocodone or Oxycodone — “I can count them on one hand.”

Internist Dr. Lynn Puana, a partner at Puana Pain Clinic in Hilo, said the goal of the clinic “is not just to give you a script and have you walk out the door.” Rather, “our focus really is trying to treat the underlying cause.”

Addiction to prescription opioids is “definitely still a problem here (on Hawaii Island). But I think one of the best ways to control the problem is to manage who is allowed to prescribe pills.”

A pill will blunt the pain, but not solve the problem, Puana said. So, the clinic monitors opioids very closely.

“We use various forms to assess a patient’s risk, and this is really ‘standard of care’ for patients who are being prescribed opioids,” she said.

For example, lab tests are used to verify that a patient is not using illicit drugs. And they also can confirm that a patient is indeed taking a full dose, as prescribed — to be certain no patient is involved in “diversion” (selling drugs on the street).

“We still, I’m sure, make mistakes,” Puana said. But, “we do the best we can do.”

No one sets out to become an addict. But it happens faster than most might expect, and pain treatment for a seemingly simple surgery can be the start of a slide into addiction. Not everyone becomes addicted. But for those who do, it can be life-altering.

A Hawaii Island man treated in October and November at a Hilo clinic said he is slowly being weaned from hydrocodone with injections of sugar solution, a technique known as prolotherapy. The injections have left his neck feeling like “jelly” instead of in constant pain.

“I was seeing all of these doctors for so long, and it was always shooting into my shoulder,” said the man, who requested anonymity in order to tell his story while he’s still in the process of getting off the opioids.

“I’m taking a third of what I used to take, within a week of my first session,” he said. He developed severe pain from a congenital neck condition and his pain was exacerbated after a fall. His hopes focus on release from pain, along with release from hydrocodone. He became addicted to it after visiting so many doctors, without achieving pain control, that he threw up his hands and gave in.

“I would love to not even have to take it,” he said.

A patient who takes opioids for two weeks will be physically addicted, Puana said. And that’s the risk of opioids.

“Patients go into Doctor X and they complain enough, or they’ve had surgery — which is a legitimate reason; somebody is going to prescribe you pain medications,” she said. Puana has “the tough talk” and says “this is not a solution for chronic pain.”

“Chronic opioid use take years, to decades, off your life,” she said. The average person, she said, three weeks out from surgery, should not need pain medicine any longer.

A red flag, she said, is if your physician says, “this is not typical” to still be in pain. If, at that point, you feel like heading to another doctor to see if that one will give you a prescription — it’s time to seek help.

“Say to yourself, ‘I really have a problem,’” Puana said.

The Puana clinic is one of those that requires patients to sign a narcotics agreement. If a patient gets opioids from another physician, you won’t get any more from Puana.

State Sen. Josh Green is an emergency room physician. Opioid addiction, he said, is an epidemic in Hawaii.

“Fatalities from (overdoses) exceeded fatalities from car accidents,” he said. “In the emergency room, I see this all the time.”

One bill passed by the state Legislature requires doctors to register with a physicians drug monitoring system.

“That step, in some states, has decreased the subcategory of people that are drug-seeking,” Green said. About 30 percent of physicians currently use it, with a goal of 70 percent of doctors and nurse practitioners.

Currently, Green said, “we’re discussing whether or not there should be a pain contract and a patients bill of rights.” That would make sure everybody has legitimate access to pain management, but also is guided away from addiction.

The goal is not to prevent people with terminal illness and others with legitimate need for pain control from accessing necessary medication. Rather, the idea is to prevent addiction while also addressing the needs of patients for adequate pain control.

“I think many people would tell you that they became an addict because they got started up on prescription pain pills,” Green said. “The Veterans Administration runs a water-tight system so veterans who need pills, they’ll get them. But they run a very tight ship.” Each veteran has a single, designated pharmacy.

Green said he views that system as a good one to emulate.

“We’re not making them addicts, so we’re not undertreating their pain,” he said.

Dr. Liza Maniquis-Smigel at the Hilo Center for Regenerative Medicine emphasized that patients need to know that there are pain-lessening treatments available that do not require opioid medications. She treats pain with injections of sugar solution.

“When you put the dextrose in, there’s an immediate relief,” she said. She also offers platelet-rich plasma treatments, in which a patient’s own blood is centrifuged to extract growth factors. Injections deliver them to tendons and ligaments.

“I think there’s a role for opioids,” Maniquis-Smigel said. But, “I know how to treat fibromyalgia without them.”

The goal is as much resolution of pain for each patient as possible, without the need for opioids. If a patient goes to Maniquis-Smigel already taking opioids, she works to wean the person off those drugs.

Halverson said Hilo Pain Clinic uses a combination of Western and Eastern medicine. A patient might be visiting the clinic but also getting massage therapy or acupuncture.

“That’s our first line of defense,” Halverson said.

The goal, Turner said, is to avoid opioids and instead get patients back to work.

“Rather than mask the symptoms with pain medicines, we’re trying to get down to the anatomic, physiologic problem that’s causing the pain,” Halverson said. “The human body is an amazing healing machine, given the right set of circumstances.”

Email Jeff Hansel at jhansel@hawaiitribune-herald.com.

 

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