Pain Specialist: Many Doctors Underprescribe For Chronic Pain
As part of our continuing coverage of the opioid crisis, Here & Now‘s Robin Young talks with Dr. Howard Fields, who has spent much of his career working with chronic pain patients. He believes many chronic pain patients are actually undertreated for legitimate, life-altering pain, and that their experiences are being left out of the current conversation about opioids.
Interview Highlights: Dr. Howard Fields
On the difference between being dependent on opioids and being addicted to them.
“Addiction really gets to the issue of compulsive overuse of a drug so that it becomes the dominant thing in your life. If you are going to your physician once a month and getting your prescription refilled and you are able to lead a normal life by taking a pill maybe three or four times a day, you’re not addicted. But if you’re spending all your time in the search of a drug, or trying to get the money to buy that drug, or stealing from your friends, or going around in other people’s medicine cabinets looking for opioids, then you’re addicted.”
On the CDC reporting an increase of 300 percent in opioid sales since 1999, but no increase in pain.
“Well I’m not going to argue with the fact from the CDC, I think they’re pretty objective and they’re correct. However, I think the important point for people to understand is that the overuse and the overdose and the deaths from heroin overdose is a separate issue from pain management. The problem is that people who are already addicted are coming in complaining of pain in order to get these drugs.”
How to tell if a patient is genuinely in pain
“Ultimately, you can’t know whether someone is really in pain. However, there are various ways which you will raise your index of suspicion that someone is getting more drugs than they need. So typically, somebody who’s been taking medication for a while will come in and say, ‘Well, I had to increase my dose because it wasn’t working, could you refill my prescription early?’ or ‘I lost my prescription’ or ‘Someone took my pills’ or ‘The dog ate them.’ Whenever you have something like that, you begin to worry. The other thing that I think is very important for physicians before they start a patient on opioid medications which are potentially addicting, although for most people they are not, is to find out whether somebody actually ever had a history of drug abuse in the past. If they use cocaine, do they smoke marijuana, do they have an alcohol abuse problem. If any of those things are present, then it should raise a red flag.”
On the lack of conversation about the underprescribing of opioids
“The greater problem is that there’s a huge reluctance in general of physicians to prescribe adequate medication for people who really are in pain and have a very low risk of becoming addicted. That’s the big problem. I think if you read the actual epidemiological data and the data from insurance companies and health organizations, it suggests that the vast majority of people are undertreated for their pain and I think that that’s in part due to the scare of overdosing and having the drugs diverted and making somebody who never was an addict and never had a drug abuse problem into an addict. My position on that is that’s very rare. I know people are being undertreated for pain. Opioids are the most effective pain relievers we now have. You want to use them optimally, but you want to use them when they’re necessary.”
- Dr. Howard Fields, professor of neurology at the University of California, San Francisco, director of the UCSF Wheeler Center for the Neurobiology of Addiction, and founder of the UCSF Pain Management Center.