Reconciling the science, politics and experiences of opioid use for chronic pain

After three years of bouncing from doctor to doctor starting his senior year of high school, Greg Bufkin found something to “knock down” his daily debilitating migraines.

Dilaudid, a potent opioid known generically as hydromophone, finally gave him relief.

For nearly two decades, Bufkin said he used his doctor’s prescription — the confirmation that “I had legitimate physical pain and that this was the only way to mitigate that” — as a crutch.

He had convinced himself painkillers were “the lesser of two evils,” with the other being his chronic pain.

At the height of his addiction, Bufkin, of Ocean Springs, was taking 90 pills a day. It took overdosing while driving with his kids in the car to motivate him to seek rehab.

Bufkin, now 39 and over two-and-a-half years clean, still deals with daily headaches.

The first time he experienced a severe backache following rehab, Bufkin popped some ibuprophen, an anti-inflammatory that was worthless at helping his pain during the years he was on opioids.

“I noticed that it had done some good. It really helped a lot,” he said, reliving his surprise.

Bufkin realized then, “opioids may have been blocking pain relief from any lesser means.”

Amid growing evidence opioids are not an effective treatment for chronic pain — and that they may actually make pain worse — Mississippi is reining in prescriptions with physician restrictions that some are calling unreasonable and even dangerous.

The psychological, social and emotional aspects of chronic pain, an undeniable tragedy that can rob people of every meaningful element of life, makes it an especially heated debate.

The Mississippi State Board of Medical Licensure, comprised of eight medical professionals, has settled on a series of new regulations it hopes will make physicians rethink prescribing opioids for chronic pain, but ultimately leave many decisions up to the doctors.

Still, new requirements, including increased documentation, will result in fewer chronic pain patients receiving opioid prescriptions.

And while “the treatment of something as subjective as chronic pain is never going to be a one-size-fits-all approach,” Dr. Anna Lembke said, more doctors are finding regulations necessary, even if they inadvertently prevent someone who might benefit from opioids, however rare, from continuing their existing treatment.

“We cannot ignore the overwhelming evidence,” said Lembke, chief of addiction medicine at Stanford University Medical Center.

It tricks you into think you’re hurting

A neurologist in Hattiesburg explained to Bufkin what happened in his brain in a way that made sense to him.

He said, “the drugs have shut down the part of your brain that might otherwise help reduce pain,” Bufkin said. “Your brain is saying, ‘if we don’t have this chemical, we are unable to counter pain.'”

With the healthier mental state he has now, Bufkin said he can manage his pain with regular massages and a soak in the hot tub at the YMCA.

Jeanne Decanter, 40, of Summit started taking opioids after a car wreck in 2002 left her with a prosthetic elbow and metal rods through her legs. The doctors put her on opioids long-term, “because they told me I was always going to be hurting.”

Decanter quit opioids a year and a half ago. She was caught selling pills for money to pay her bills (after she had spent her bill money on more pills).

Before that wake-up call, “I would have been one of the ones who would get angry if you told me that I might be addicted or that I didn’t need them. You could not convince me that I did not need them.”

“It tricks you into thinking you’re hurting so you’ll take more,” Decanter said. “A lot of people that are still in chronic pain and still taking that medicine, they have no clue that the medicine is doing that to them. They’re probably thinking the way I thought, ‘The doctor is saying I need it, so I need it, and it helps.’ They’re not comprehending that they’re probably already addicted to it and they don’t even know it.”

Decanter’s experience — worsening pain sensitivity from the long-term use of opioids — is called opioid-induced hyperalgesia. The prevalence of this paradoxical reaction is unclear.

The phenomenon is different, though sometimes hard to distinguish from tolerance, which makes the painkiller less effective over time.

JAMA published research in March showing opioids were no better, and in some cases slightly worse, than non-opioid pain killers such as Tylenol and acetaminophen at treating chronic back pain, hip pain or knee osteoarthritis pain. The randomized study looked at 240 chronic pain patients and monitored outcomes over one year.

“If you had an antibiotic and it is widely accepted that it is fueling infections as opposed to fighting them, what would they do? They’d pull it off the market,” Bufkin said.

There are no studies beyond 12 weeks that show opioids work for chronic pain, and longer studies are necessary to show their efficacy over time, experts agree.

“I can personally tell you that, yes, I still hurt on a daily basis, but it is nothing compared to the way that I hurt when I was on them,” Decanter said. “They just had a way of tricking me physically, emotionally into needing them.”

The pills had another effect, too.

“Nothing I did brought me any type of joy — nothing. I was always emotionally numb,” she said. “Being 18 months without it, I’m still breaking out of the emotional numbness.”

Explained Lembke: “Opioids rewire the brain, eradicating our ability to experience pleasure in so-called ‘natural’ rewards: a good meal with friends, a beautiful sunset.”

When opioids are ingested, the brain responds to the dopamine surge by producing less dopamine, said Dr. Scott Hambleton, medical director of the Mississippi Physician Health Program.

Decanter had spent “14 years shoving medication in my mouth to numb physical pain and in turn numbed emotional pain.”

“I’m sure there are residual things going on in the brain.”

The crackdown

These are among the reasons Mississippi is cracking down on doctors prescribing opioids for chronic pain.

Through the exercise, state leaders, law enforcement officials and medical professionals are acknowledging both the lack of evidence of the painkiller’s efficacy and the role of overprescribing in the worst opioid epidemic in U.S. history.

At the height of the epidemic, roughly 115 people died each day from opioid overdoses, 40 percent of those deaths involving a prescription, according to the Centers for Disease Control and Prevention.

In Mississippi — a state with some of the highest rates of high blood pressure and cholesterol — hydrocodone, an opioid, is the most prescribed medication. The same is true in 10 other states.

Doctors in Mississippi wrote 3.3 million opioid prescriptions in 2017 — more than there are people in the state.

After several months of public hearings and revisions, the medical board’s new opioid prescription regulations are virtually completed and pending approval by the Occupational Licensing Review Commission.


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