I prescribe opioids every day. Opioids are effective, relatively inexpensive, and safe. In general, if you take too many, you fall asleep which typically prevents you from taking more.
Cancer patients can experience severe pain. Pain occurs when the cancer has eaten its way through a bone or a tumor compresses a vital organ. Pain often prevents patients from lying still for their radiation treatment. I pride myself on targeting tumors with precision and if my patients are writhing on the treatment table, I cannot risk missing the tumor and delivering unnecessary radiation to other organs. Lately, patients are returning to my office telling me that their pharmacy won’t fill the opioid prescription without authorization. Apparently, a written prescription with my signature, DEA number and license are no longer sufficient. Our office returns the authorization paperwork promptly, yet the insurance company takes at least 48 hours to provide the authorization, and often longer. The strategy for combating opioid abuse is to make opioids less accessible. This simplistic approach is resulting in delayed cancer treatment and unnecessary suffering. Opioids are not the problem. Addiction is.
More and more of my cancer patients are hesitant to take the pain medication that I prescribe. They are afraid of “getting addicted” or they want to know if these are the same drugs that they’ve heard about on TV. The answer is yes. Opioids, such as oxycodone, hydrocodone, and fentanyl have been very successful at relieving cancer-induced pain. Opioids are generally well-tolerated and side effects such as fatigue and constipation can be managed. Most people would have to make a conscious effort to abuse these drugs. Unfortunately, some people do. In November 2016, the U.S Surgeon General released a report on addiction, estimating that 21 million Americans have a drug or alcohol addiction.
For all the above reasons, people become addicted to opioids, but does that make the drugs the problem? Is limiting the ability to prescribe opioids and limiting the ability for people to obtain their opioid prescription the answer? Instead of making it more difficult for cancer patients to get pain medications, we should be targeting our efforts (and federal funding) to understanding addiction. Addiction is the problem because there is always going to be another opioid, or drink, or recreational drug that comes along.
This month’s National Geographic magazine explores a new method of inhibiting the brain’s desire for opioids or other addictive substances. Author Fran Smith discusses an experimental technique used by an Italian psychiatrist who has treated addiction for many years. Dr. Luigi Gallimberti uses a technique called transcranial magnetic stimulation (TMS) to stimulate a part of the brain responsible for inhibition of behavior. This picture from National Geographic article shows a cocaine addict undergoing treatment with Dr. Gallimberti who is applying TMS (electromagnetic pulse) on the left side of the patient’s head. Essentially, stimulating the pre-frontal cortex with the goal of reducing the patient’s desire for cocaine. The technique has been so successful that it is now being tested in other trials in conjunction with Dr. Antonello Bonci, a neurologist at the National Institute on Drug Abuse (NIDA) here in the U.S.
NIDA Director Dr. Nora Volkow’s presentation at the April 2017 National Rx Drug Abuse and Heroin Summit also describes the push for pharmaceutical companies to develop non-narcotic medications for treating pain. While I’m hopeful this will yield results, this attempt is not new, as many drug companies in the 1980s and 1990s had the same goal as opioids gained in popularity.
Dr. Nora Volkow’s, NIDA 2016
Dr. Volkow’s and Dr. Gallimberti efforts are excellent examples of research that needs to be done. I also concur with the CDC’s Guideline for Prescribing Opioids for Chronic Pain. Prescribers need to be educated on non-narcotic options for pain management. Insurance companies not approving a valid opioid prescription? Pharmacies not filling a valid opioid prescription? These intentional delays are not a solution to the opioid epidemic. These delays and increased paperwork are preventing cancer patients from receiving the quality care they need.