October 18, 2017
Misconception That Leads to Opioids
by Chad Gray
We physicians are not applying the right treatment to the right patient to the right body part at the right time.
No physician wants to create an addicted patient. In almost all cases, they simply want to mitigate patients’ pain. Good intentions with a bad strategy.
The breakdown in the system stems from a poor understanding of pain and how to diagnose and classify it correctly. In effect, you have to match the treatment to the patient’s condition, which means you need to possess a reliable method of diagnosing pain.
Human beings experience three types of pain: 1) thermal pain — quite rare and only produced in the very ill and systemically sick patients; 2) chemical or inflammatory pain — pain that is mediated through a release of chemicals at a site of injury (this pain lasts five to seven days, occurs when trauma happens and is only present in 2% to 5% of all patients in pain); and 3) mechanical pain — pain that is mediated through/by distortion or pressure on tissue (90%-plus of all pain that humans experience).
Bend your finger back as far as you can until pain is produced, and you have just experienced mechanical pain in its purest form. A bulging or herniated disc in 95% of all patients produces pain because the wall of the disc is being distorted or strained just like your finger was when it was hurting.
See also: Opioids: Invading the Workplace
You can’t treat mechanical pain with a chemical intervention ( pills and injections). You can’t treat chemical pain with a mechanical intervention. Makes sense, right?
The problem is that we have a system built around using chemicals to manage pain and providers who receive less than two weeks of education in medical school around how to adequately assess and diagnose patients in this space.
The evidence is overwhelming. There are dozens of studies that show little influence on back or joint-related pain (less than one point on a 10-point pain scale, and that’s in only 30 % of the cohort) when using opioids, analgesics, muscle relaxants and steroids, yet every PCP and specialist in the land has them as the first stop off for MSK (musculoskeletal) patients. When the simple analgesics and muscle relaxants don’t work, then escalate to opioids.
Numerous studies show that less than 5% of patients experience any change in back pain when epidural steroids or transformational injections are used to put the medicine at the supposed source of symptom. Why are these studies struggling to find treatment effect on patients in pain with some of the best-trained examiner/physicians in the world conducting the study? It’s simple. We don’t train them to assess patients in a reliable way and to match chemical patients with chemical interventions and match mechanical patients with mechanical interventions (surgery and movement-based strategies).
See also: 6 Shocking Facts on Opioid Abuse
90% of opioids are prescribed for back or chronic joint pain. The solution to the crisis is to teach providers to reliably sub-group patients into their appropriate pain group. Mechanical patients only get mechanical solutions, and chemically dominant or inflammatory patients get chemical treatment.
Our failure to do this has allowed us to continue to use treatment methods long ago determined to be ineffective in this population and also forces providers to become inventive. We blame the patient; we claim they are gaming the system; we think the problem is psychosomatic or a construct in their mind — when in reality we are not applying the right treatment to the right patient to the right body part at the right time.