By Autumn Pace
Last week Monday started as any normal Monday would – lots of coffee and a long traffic-filled commute to work before I finally walked in to the clinic. Within a few minutes of opening, phones were ringing non-stop and everyone’s stress levels were through the roof. One of our patients had overdosed on narcotics just a few nights before. This was the first of any patients I’d come in contact with that had passed away, although I know it will not be the last during my medical career. However, this was different as it was completely preventable.
Narcotics are one of the most widely used drugs in the US with an estimated 2.1 million people in the United States being addicted to opioid pain relievers. Narcotic overdose is also extremely high in our country with more than 28,000 dying yearly on average, with half of those overdoses deaths involving a prescription opioid. Regardless of the statistics, narcotics are still widely prescribed and are thought to be relatively safe by the general public and even primary care physicians. A study posted in the Clinical Journal of Pain in 2015 showed the misconception that many primary care physicians have as almost half of them believed that opioid pills that are formulated with physical barriers to prevent being crushed, snorted, and injected are less addictive; while this is not true.
As a physician in training, what will you do when you have a patient complaining about chronic pain that is requesting narcotics on multiple occasions?
One alternative to opioids for the treatment of chronic pain is acupuncture. Multiple recent studies have attempted to quantify the effectiveness of acupuncture on chronic pain compared to the effectiveness of opioids. One recent study performed a meta-analysis to determine the effectiveness of acupuncture for cancer pain and preliminarily found that acupuncture was more effective than opioids at reducing cancer pain.
Another alternative, at least in some states currently, is medical marijuana. The main pain relieving substances within marijuana are tetrahydrocannabinol (THC) and cannabidiol (CBD). Depending on the patient’s diagnosis and symptoms, the ratio of THC to CBD differs. For example, most patients with seizures will require a higher ratio of CBD:THC while most chronic pain patients will require a more equal ratio of CBD:THC. Marijuana has been proven to be significantly effective in reducing pain in patients with multiple sclerosis. Additionally, chronic pain is an approved condition for certification for medical marijuana in at least 12 states.
A third alternative to opioid prescriptions are supplements with certain vitamins and minerals. Multiple studies have found a high prevalence of critically low vitamin D levels in patients with non-specific musculoskeletal pain. While this connection has been found, there have not been any large studies that found significant evidence to support the effectiveness in supplementing Vitamin D to reduce chronic pain. However, the side effects of Vitamin D supplements are very minimal with patients experiencing headaches, loss of appetite, dry mouth, nausea, or vomiting if too much Vitamin D is consumed. Physicians should be cautious about prescribing Vitamin D supplements for patients who are at risk for high serum levels of calcium that can be potentiated by Vitamin D supplements. While there are no studies which show concrete evidence demonstrating the effectiveness of Vitamin D to reduce pain, the potential benefits outweigh the potential risks.
With multiple alternative treatments for chronic pain that have minimal risks compared to the risks associated with opioids, which would you choose for your patients?
AMSA Wellness & Student Life Committee