February journal club was lead by Shannon Walsh. Journal club review was written by Chris Unterberger and April MacIntyre.
Necedah (nehSEEduh; /nəˈsiːdə/), a small town in central Wisconsin not far from nor unlike my hometown, suffers from a small economy. This leads to problems like a lack of resources and difficulty retaining professionals. However, in addition to normal small town challenges, Necedah has a problem that all cities across the US share, whether big or small, North or South, rich or poor: opioids.
The underlying cause of the news-captivating opioid crisis is pain, a feeling so primal and universal that it affects everyone, even Necedah, the subject of one of our articles from journal club, and other small towns in Wisconsin. But humans have been treating pain for as long as humans have been feeling pain, so what’s changed? In February journal club CaSPers discussed topics related to pain, racial disparities in its alleviation, how its treatment has spiraled out of control, and possible solutions. But, no matter the cause, internal biases, or hidden solutions for the over-prescription of opioids for the treatment of pain, intervention must be taken to save small communities like Necedah.
The Pain Pipeline
The Pain Pipeline is simple. Someone sees a doctor to attend to their injured back or similar nagging pain. The doctor gives them some prescription strength ibuprofen. Ibuprofen may relieve some of the pain, but eventually becomes ineffective as their pain persists (or the patient further injures themself). The doctor now prescribes oxycodone. The patient finds initial relief, but soon requires more and more oxycodone to fight their pain. At some point, the patient either runs out of their prescription or simply needs a more potent drug, leading them to heroin. It’s not long before the patient desires such a large dose of this opioid that they overdose. It’s a tale as old as time. Except it’s not; the opioid crisis has very distinct roots and a timeline.
Opioids are drugs, recreational or prescribed, that act on opioid receptors to relieve pain and induce anesthesia. Opioids have been around for a long time, but synthetic opioids became available in the 1990s with the promise that they were addiction free. Unfortunately, they were addictive, misused, and abused and, due to continued misinformation and lobbying for their prescription by the drug companies that created them, they were prescribed more than ever in the early 2010s. Although overdoses have decreased in recent years, the number of deaths due to opioid use is still too high. Why is this?
Without exhaustively exploring the complexities of the US healthcare system, much of Western medicine is focused on eliminating pain. Compared to the perception of pain in other parts of the world, the US is more concerned with eradicating pain altogether rather than subverting it. The problem is that eliminating all pain is nearly impossible and the philosophical arguments for allowing and valuing pain in life are shunned in Western society. Additionally, this Western disdain for pain is coupled with Americans’ propensity to react to injury rather than prevent it. The slippery slope in the Pipeline begins with this frame of mind.
The Pain Pipeline slope is further greased by the fact that many of the small towns with opioid and pain issues like Necedah have limited access to specialized physicians. Without the proper training in addiction prevention and treatment, rural health primary physicians are susceptible to over-prescription of opioids. Without specialized doctors, small communities will continue their ignorance and treat pain like they always have: with increasingly powerful drugs like fentanyl.
Another challenge in the pipeline that makes it even more difficult to curb this epidemic is that pain is subjective. Both the patient and the doctor are limited to a series of frowny or smiley faces to communicate their needs. Additionally, no quantitative biomarkers exist for the presence of pain so it’s hard to predict, diagnose, and standardize across patients. Lastly, pain can be intolerable, even driving some to the point of insanity. Pain can induce desperation, driving patients to addictive medicines and away from slower, less destructive treatments such as physical therapy.
Racial Bias and the Protective Effect
Pain or death? It’s a tough choice, but for some the choice is already made for them. We were all surprised in journal club to learn that there was a protective effect for Black Americans that minimized the number of opioid deaths in that population because of racial bias. Largely driven by racist beliefs, Black Americans have classically been perceived as “tougher” and less inclined to feel pain compared to their Caucasian counterparts. This perception resulted in doctors under-prescribing strong pain medication to this group. Although this prevented the death of approximately 14,000 Black Americans, these patients were forced to unnecessarily endure undiagnosed pain. In mostly white communities like Necedah, this double-edged protective effect may have affected less patients, but the underlying racial biases still exist and contribute to a disparity in healthcare.
Solutions to the Pain Problem
So far it sounds like all that needs to be done to reverse this epidemic is to completely overhaul the mindset of every prescribing physician in America and remove all racial biases throughout the developed world. Doesn’t sound reasonable, does it? Well don’t panic! There may be simpler ways.
Uganda—a country stricken with issues such as compromised free speech, political turmoil, and gender freedom—needed an answer for its shortage of painkillers. For patients suffering from extreme pain, doctors in Uganda rushed for a tried and true method: morphine. Doctors found that administering powdered morphine mixed in water could cheaply, safely, and effectively provide a drinkable dose to their most anguished patients. They saw that not only did the solution work to relieve their patients of pain, but no addiction to the concoction developed. Patients could be trusted with a two-week’s supply to take home and prepare themselves. Though this story is revealing, there are major differences between Uganda’s health system and the US’s, so the direct translation to an American clinic may be ineffective.
In other medical traditions outside of Western countries, pain is treated with a variety of alternative means in addition to painkillers. Acupuncture has been a practice in China since possibly 6000 BCE. Massage is a luxury in the West but a therapy in other places. There are stories of meditation alleviating chronic pain. Unfortunately, in the US, these alternatives aren’t always available (especially in small communities) and often are not covered by medical insurance due to the lack of research supporting their effectiveness. Nonetheless, alternatives to highly addictive opioids should be explored and this search for alternatives has even made it into the mainstream Democratic political campaigns.
Pain management is chock full of issues, ironies, and solutions. The US is fighting itself with its dependence on quick and cheap pain relief, leaving small towns like Necedah feeling the brunt of the delay in finding alternatives. Without investing in long-term pain management and—more importantly—pain prevention, the demand for stronger painkillers will only grow. To add insult to injury, the racial discrepancies found in pain treatment only makes finding a solution for all Americans more difficult.
It is time to find alternative solutions to modern pharmaceuticals. Although alternatives like acupuncture, meditation, and prolonged physical therapy are available to patients in urban areas, rural communities lack these alternatives. Qualified specialty pain management physicians need incentives to work in rural areas and share their knowledge with current doctors serving those areas. Alternative treatment opportunities need to be available in public hospitals in rural areas. Bias training or other methods to promote inclusivity could help curb racial biases seen in the system today. Science is working to identify biomarkers of pain and pain tolerance. Lastly, liquid morphine may need to be explored as a relieving alternative to opioids. Americans can do a lot to combat the opioid epidemic by looking for alternative means of pain relief. This just might save the residents of Necedah. It just might save you.