New guidelines call for cutting opioid doses – but where does that leave those plagued by chronic pain?
By: Elaine Della-Mattia
Published on: August 9, 2019 | Last Updated: August 9, 2019 4:19 PM EDT
Since the 1990s, morphine has been used by physicians as a strong pain reliever for acute and chronic pain. But more recent medical expertise has clinical doctors scaling back on doses, sometimes leaving patients with nothing to turn to.
New medical evidence, a growing opioid crisis across Canada and North America and new guidelines monitored under the watchful eye of professional associations, including the College of Physicians and Surgeons, has resulted in physicians scaling back dosages of morphine and other opioids, opting for other pain prevention techniques.
In the meantime, the legacy patients who had been regularly prescribed morphine or other opioids, some more than today’s recommended limits, contend they are falling through the cracks with nowhere to turn.
Walter Shelly was injured in a work-related accident in 1975. He’s undergone seven surgeries on his spine, including a spinal fusion, and continues to suffer with chronic pain. He’s been prescribed morphine since 1999 and his doses over the years had increased to help him cope with the pain. It allowed him to tolerate the constant pain and live a “fairly reasonable” life for many years.
But that’s all changed now. In more recent years, the dosage has been reduced as a result of new medical guidelines, but Shelly says that’s making it more difficult for him to lead any sort of normal life and often finds himself lying in bed to cope with his pain.
The scenario is one that is all too common to Dr. Robert Maloney, who spoke to The Sault Star on the broader issue of opioids, the changing medical guidelines and what’s in store for future pain management.
While a variety of opioids was available through prescriptions for decades, Tylenol 3 was the most common pain killer used before the 1990s, said Maloney, the lead physician at Sault Ste. Marie’s Rapid Access Addiction Medicine (RAAM) clinic.
But then science evolved. The mid-1990s brought about new medical interest in chronic pain and new tools to alleviate it. Physicians were professionally obligated to recognize and prescribe to reduce chronic or acute pain and the palliative care community said morphine and opioids could serve as an effective and safe method of treatment and should be considered.
“Over time, some physicians became more familiar with prescribed opioids for chronic pain and the entire medical community ventured in that direction,” he said during an interview with The Sault Star.
It was a time when high doses of prescribed opioids were administered locally and across the country.
“It became a permissive culture in the early 2000s. I think we helped a number of people, but what we didn’t realize at the time was the downside that we now see. We see the downside of using high levels of opioids,” he said.
Maloney witnessed that first hand with one of his own patients overdosing from opioids.
The newest medical evidence leaves Maloney and his colleagues with a new challenge to learn and manage pain effectively – without or with only small doses of opioids.
“We’re seeing a swing in the pendulum and that comes with chronic pain national guidelines of 2011, which were updated in 2016,” he said.
Those guidelines recommend that patients not be administered more than 90 mg of morphine a day. Doses greater than the prescribed guidelines are believed to increase the potential of harm and cause severe side effects for patients. That makes the risk of morphine use greater than the intentional purpose of reducing chronic pain, he said.
Shelly finds himself exactly in that position. With recent reductions of his dosages, his chronic pain has returned, making him unable to cope for long periods.
Maloney agrees that legacy patients who had been prescribed doses above the newer recommended limits may find themselves in difficult situations.
A physician’s objective is to safely reduce the dosages, but many of the patients are older persons who may have other complications. Not all will see reductions to the levels of the new guidelines and the guidelines themselves are not clear on how a safe reduction should be made.
Shelly says he’s dependent on morphine — and has been for years.
But being dependent is not the same as being a drug addict, Shelly argues.
Other pain medications affected his stomach and organs and resulted in massive weight loss. It’s also been discovered he is allergic to methadone, a drug often administered to wean patients off opioids.
“Doctors are taking me off medication that is working for me. They’re trying to change medication I use for pain and treat me as if I have an addiction,” Shelly said. “I am dependant on (morphine) to help me with the pain but I’m not a junkie. I’ve always used my medication correctly, as it’s been prescribed. ”
A psychological tolerance of opioids is difficult to deal with, Maloney said.
Part of the problem is that individuals develop a tolerance to the opioid, which has resulted in doctors increasing dosage to get the same benefits.
“We don’t do that now because we’re more aware of the harmful effects, which include sleeping disorders, depression and a whole array of physiological issues,” he said.
Morphine is a drug that is part of the opioid family. It works with the brain and changes how users feel and react to pain. Morphine is a highly addictive drug and, with drug users, can have the same effect as heroin.
Newer physicians are often reluctant to even prescribe morphine or opioids to patients.
Some patients, who have been on morphine to curb their pain for decades, are finding it more difficult to cope with everyday challenges as prescription limits are reduced or altered to another drug that may not be quite as effective.
Shelly finds himself in that same position because his dosage has increased over the years as his tolerance to the drugs increased.
Maloney admits that a slow withdrawal of opioids can reduce the risk of injury but not the patient’s pain. It can also be difficult to achieve, especially with patients who have suffered multiple injuries or surgeries.
“Sometimes it’s also difficult to change an individual’s mindset that increasing opioids are not helping but only increasing the risk,” he said.
Shelly said he believes that he’s not alone in suffering as a result of the overall opioid crisis in Canada and the push for physicians to reduce prescriptions. He fears that the cutbacks to the morphine will encourage individuals such as himself to self-medicate.
“I don’t want to do that and don’t want to do anything illegal to hurt myself,” the 66-year-old Sault Ste. Marie man said.
Maloney admits that the risk of self-medication is there, and he has seen patients turn to streets drugs. He then sees them in the addiction clinic.
“That’s unfortunate and unnecessary and unintended in the guidelines,” he said.
The key is for both the physician and patient to define levels of pain together and determine how a dosage can be reduced and still achieve a pain manageable lifestyle.
Maloney can’t begin to guess the number of legacy patients in Sault Ste. Marie who could be in a difficult position because of the need to reduce the opioid crisis. Statistics, local or otherwise, are not available.
In the meantime, with emerging medical information, those prescribed opioids – and high dosages – are faced with tough times. Some may be able to adapt to lower doses, while others may not and the fear of falling through the cracks is real, like Shelly suggests.
Another picture that needs to be addressed by the medical community is how to deal with chronic pain patients in the future.
Maloney and several of his colleagues are examining the option of creating a chronic pain program in Sault Ste. Marie. The idea, still in its infancy, has seen a group of professionals visit McMaster University’s chronic pain clinic and a professional conference is scheduled in Sault Ste. Marie for next April that will deal with chronic pain and addictions.
“Communication is the key. It’s a complex issue that involves multiple agencies for treatment, enforcement and education,” he said.
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