Gregorian chant filled my ears as I looked out the floor-to-ceiling window of the town gym. The morning sunlight hit the yoga studio’s floor in beams, shadows dancing as cardinals hopped from branch to branch on the trees outside, everything connected, just as it should be during yoga.
I had been practicing for about three months and thought I was ready to take my stretches to the next level. I was wrong.
There was no telltale crunch or sharp pain as I lay on my back, tossed my legs over my head and forced them to touch the ground behind me. I knew I was hurt only when the slight stiffness in my neck hadn’t disappeared by the next day.
By the next week, I couldn’t fully turn my head, and by the next month, my right arm started going numb. I took myself to the doctor.
That was June 2014, and I didn’t know it then, but I would eventually find myself in chronic pain, on a journey that would one day have me brushing up against growing concerns about prescription painkillers.
As I would discover, the medical community and government officials have been hashing out new guidelines about opioid prescriptions as overdose deaths have surged. Many people with chronic pain say opioids are the only drugs that provide any relief, but with 259 million prescriptions being written a year — that was the number for 2012 — the Centers for Disease Control and Prevention is developing recommendations that would urge providers to limit doses of painkillers and to find other treatments, including physical therapy and different drugs for injured patients.
My yoga mishap left me with a herniated, or slipped, disk in my spine. The softer center of the disk was protruding through the hard exterior, pinching a nerve. At the time, treatment was simple: physical therapy and a two-week course of steroids for inflammation. Surgery, the doctors said, was a last resort. It took months, but by the fall I was on my way to recovery.
Then I reinjured myself, this time during an abdominal workout. Back came the numbness, the headaches, the constant throb at my neck, shooting up toward my eyes and down my spine. I visited the same urgent-care clinic I’d been to the first time around. They prescribed me a week of steroids and a nonsteroidal anti-inflammatory drug, and they gave me what I’d gone there for — a referral to physical therapy. But this time, when I went through my discharge paperwork at home, I noticed a memo that seemed to have been placed there by accident as it couldn’t have been talking about me.
Across the top, in big bold letters, it read: “Pain Management, Chronic.” Underneath, the memo started with “You have a painful condition that has required frequent use of narcotic-type pain medicine.”
It went on to recommend that I see my primary-care physician, and it told me to expect to sign a pain contract there, explaining that a pain contract is “a letter from your doctor which describes what pain medicine you may receive, how much and how often.” Once I’d acquired this contract, I was to bring it with me every time I returned to the clinic.
This is all well and good, except that I’ve never been prescribed narcotics, opioids or any other addictive medication for my neck. As far as I could tell (the clinic declined to comment for this article), I received the documentation based only on the fact that this persistent pain in the neck has been bothering me for a year now, pushing it from acute to chronic.
The United States uses 80 percent of the world’s opioids, according to a 2010 article in Pain Physician Journal, yet it makes up less than 5 percent of the world’s population. And 28,647 people — a record number — died from prescription opioids and heroin overdoses in 2014, according to the CDC.
Emergency rooms, clinics and doctors have come under scrutiny in recent years as painkiller addiction has increased along with the death rate. A recent Johns Hopkins Bloomberg School of Public Health report found fault with the entire supply system of pain medication, asserting that doctors too often prescribed painkillers in excessive amounts and for conditions that did not warrant them.
Last year, the Drug Enforcement Agency tightened up rules on dispensing some painkillers, and the CDC is expected to announce new guidelines soon about how doctors should prescribe painkillers.
Robert Wergin, president of the American Academy of Family Physicians, says that clinics and doctors are playing it safe by making broad use of contracts such as the one I received.
“Clinics need to cover their backs,” he told me. “They assume because you’re in a chronic-pain category, they should give you the memos. That way, in case they get audited, they can show their paper trail and prove that they’ve done due diligence.”
Doctors do not want to send patients away in pain, Wergin said, but they also do not want to harm patients or get in trouble by overprescribing pain medication.
The Hopkins report suggested more-stringent guidelines for prescribing opioids, calling on states to overhaul the way they monitor chronic pain treatment and adopt procedures — such as urine screening and collecting data on prescriptions given to patients — to make it easier to identify who may need treatment for substance abuse.
Doctors are divided. Lynn Webster, a former president of the American Academy of Pain Medicine and the author of “The Painful Truth: What Pain Is Really Like and Why It Matters to Each of Us,” criticized the Hopkins report.
“I am amazed that one of our finest educational institutions in America failed to address the most important source of the prescription drug abuse problem in their report,” he said. “Not once did the report discuss the lack of safe and effective treatments for pain. The report lacks attention to the needs of people in pain.”
Caleb Alexander, lead author of the report, said that while he agrees that new and more effective pain treatments are necessary, the point of the report was to suggest ways to make current treatments safer.
“The goal was to make recommendations to reduce an incredibly high rate of injury and death associated with opioids,” Alexander said. “My concern with focusing on safer treatments is that it distracts from the epidemic of prescription opioids.”
Many doctors agree that new federal guidelines — including a full physical exam and medical history on each pain patient, starting patients on the lowest effective dose, implementing pain contracts and closely monitoring pain medication use — are necessary.
Growing awareness of the problem and discussion about the soon-to-be-released CDC guidelines are already resulting in better interactions, Wergin said.
“Before, we were trying to treat pain in a less structured environment, and it was harder to see the full picture,” he said. Now states are keeping more detailed records and centralizing them “so the patient’s entire care management team has easy access to what exactly is going on at any given time.”
Without pain contracts and without knowing a person’s history, clinics could accidentally prescribe a patient too much pain medication. However, pain contracts are being administered broadly, even to patients — like me — who have never taken opioids. Some critics say that can damage the doctor-patient relationship.
“With chronic pain, you have to have that trust and relationship, to help people feel like people. Sometimes we can be labeled as prescription writers,” Wergin said. Urgent-care clinics “have it harder than I do because they don’t know their patients. They’re doing the best they can, and they want the patient to be satisfied with their service, and so they want the pain gone for the patient.”
While some parts of the notice I received didn’t apply to me specifically, Wergin said, the rest of the advice was sound. “Pain patients should have a primary-care doctor,” he said. “The outcomes will be better. They’ll get to know their doctor over time, and the doctor will come to know them as well. There’s a level of trust there.”
But Webster said the guidelines are doing nothing to promote best practice. “Guidelines are superficial,” he told me. “They don’t look at the core of the problem, which is pain. You cannot solve the prescription drug problem until you solve the pain problem unless you want to ignore the suffering of 100 million Americans.”
He characterized the Hopkins report as focused on risk management and law enforcement options, without attention to the needs of people in pain.
“The long-term solution is that we need safer, more-effective, nonaddictive drugs developed and available for pain patients. No one is working on this. That’s a failure within the system.”
Alexander said the development of those types of drugs is a laudable goal, but it is not practical in the immediate conversation.
“Treatment developments do little to help the people dying today, and today 44 people will die of prescriptions to opioids,” he said. “We are looking at the immediate future and the likelihood of turning this around right now. We want comprehensive, concrete, evidence-based solutions.”
Webster said he was neither pro- nor anti-opioid. “I am pro-patient. And today, opioids are our only option to treat many chronic pain conditions. It’s up to us to develop better methods.”
As for this patient, I intend to stay with my two ibuprofen a day — and go to my primary-care doctor if I need help with pain.
Cunha is a freelance writer.