Narcotics and Analgesia in Latin America: Issues related to managing acute pain in chronic opioid patients


This article is part of a new series that explores issues in medical tourism.

The geopolitical landscape of drug trafficking?

As a writer who has written on both Colombia and Mexico, the most frequent questions I encounter from friends, colleagues and acquaintances are almost always related to drugs and drug-related violence.  As I’ve mentioned in previous posts, the real risks of crime and violence affecting medical tourists is actually quite small in many of these areas, despite media headlines*.   Questions related to the drug trade are for all intents and purposes outside of my area of expertise..   However, this does bring up some other related issues that are increasingly relevent for our on-going discussions about medical tourism.  But, first some background –

drugs2

The Latin American Drug Problem?

Just ask a Mexican, Colombian or another person from Latin America and they will tell you, the United States is the place with the drug problem.

Not only that, but the majority of Latin American countries hold the USA as responsible for fueling much of the violence that has devastated these countries in recent years.  Erik Vance over at Slate.com recently published an excellent essay on this topic which explores the role and collective responsibility of American citizens for drug related atrocities under the guise of a Friday night high.

This isn’t Colombia Reports, its Latin American Surgery.com

But talking about the politics and trade issues regarding the growth, harvesting, and distribution of illegal drugs isn’t really the focus of my work.   Healthcare is, so my interpretation of issues regarding drugs is very different – almost like another language.  If you could see inside my head, and watch my thought processes, it would look a little like this:

Drugs —> Narcotics —-> medications for pain —–> treating pain —–> international / cultural issues related to pain and treatment of pain —> who is most heavily affected by this?

When I hear “drugs”, I think “medications.”  When I think of medications, or more specifically, narcotics – I don’t think of tiny, little bags littering the street in Medellin, but the somewhat vague medical definitions for narcotics..

drugs

Narcotics, Narcotics, Narcotics…

The definition of narcotics depends on the discussion..

Legally, a narcotic is any medication or drug that is prohibited/ restricted / illegal.  Thus while the government classifies amphetamines, MDMA (ecstasy) or cocaine as narcotics, healthcare providers usually don’t.

Medically, narcotics usually refers to opioid compounds or other medications used to relieve physical pain.  More recently, the term analgesics has replaced narcotics in the everyday vernacular.  When we refer to narcotics, we are usually talking about using medications in a therapeutic fashion specifically to treat pain – like prescribing Percocet or Lortab for pain after surgery..

pills2

A kid in the candy store

Americans are the kings of narcotics. But unlike the common perception of drug abuse being isolated to crack pipes, cocaine and heroin junkies – the majority of drug abuse in the USA is derived from legal prescription medications, readily available at large chain pharmacies.

CVS and Walgreens versus the Colombian drug dealer

It’s usually a Colombian or Mexican drug dealer – at least on the latest episode of modern crime dramas.  I guess that’s because the truth is a lot more mundane.  In actuality, CVS, Walgreens and any number of local pharmacies are the real ‘drug dealers’ for many Americans.

We prescribe, we use, and we abuse at astronomical rates.  No other country comes close to being as heavily medicated as ours. Not only have overdoses and addiction rates skyrocked, but so have the cases of “Chronic non-cancer pain” treated with long-term narcotics.  Some of this use is legitimate, some of it isn’t but anyway you look at it – we have a problem.

The prescription drug problem: Overdoses, addiction and chronic pain

In  a recent Medscape article by one of the foremost experts on chronic pain,  chronic pain management and addiction medicine,  Laxmaiah Manchikanti in “Lessons Learned in the Abuse of Pain-Relief Medication_ A Focus on Health Care Costs” estimates that there are over 100 million chronic pain patients in the United States. 

That’s a lot of pills and prescriptions.

But even if we ignore issues of prescription abuse and misuse, there still remains a large segment of people with chronic pain and chronic opioid use.  These people aren’t abusing their medications, but they are using opioid medications over long periods of time, often in escalating doses.

Chronic pain and Chronic Pain treatment with opioids

The problem chronic pain patients face is one of tolerance.  When patients are treated with opioid medications, including long-term opioid medication regimens for problems like chronic back pain, tolerance to these drugs and their effects occurs.  This means that it takes more of the medication to produce analgesic (and other) effects.

For example, a dosage that would make an opioid naive patient comatose for example, may only serve to reduce pain from a “10 [unbearable agony]” to an “8 [excruciating] ” in a patient with tolerance.

While an isolated prescription for Percocet after major surgery or an injection of morphine in the emergency room for an acute fracture shouldn’t cause any long-term problems, many of people with chronic use have developed a significant tolerance to these medications.

Tolerance makes obtaining adequate analgesia in acute pain difficult

This means that the ‘standard’ doses of pain medications that are usually ordered after procedures may be inadequate to manage their pain.  Huxtable et al describe the problem of maintaining adequate analgesia in opioid tolerant individuals during episodes of acute pain in his 2011 review, which gives a comprehensive overview of the issues involved.

But, if you can imagine the scenario of an opioid tolerant patient awakening from major surgery, only to find out that the prescribed medications aren’t working  – then you have a pretty good idea of how potentially traumatic and devastating this could be.

If you are planning for surgery: 

– Pain management planning (baseline pain score, realistic pain management goals, multi-modal therapies, and thorough review of medication history)

But more critically, people with increased opioid tolerance need to talk – to their providers and their caregivers about realistic expectations of post-operative pain control.  Together, patients and providers should review their pain medication history, as well as baseline pain scores.

Also contributing factors like depression or other emotional distress should be addressed prior to surgery.  (Even if you don’t have a diagnosed depression – antidepressants can often help alleviate pain).

For example:

Patient P is scheduled for a knee replacement.  While P’s knee has been hurting for some time, P’s chronic arthritis pain is mainly centered in P’s low back.  P takes several medications for his back pain, including oxycodone and has done so for several years since a workplace injury landed him in the emergency room with a herniated disk.  Now P is concerned about his pain after surgery.  

What are some of the issues that P faces?

If prior to surgery, patient P reports a chronic (baseline) pain level of 6 in his back (on scheduled, long-term narcotics):

– obtaining pain relief (a score of 3 or less) might be impossible.  It is almost certainly impossible that the same medication regimen used for opioid naïve patients is going to be equally effective for patient P.

 After a frank discussion with his/her surgeon during pre-surgical evaluation, P’s doctor anticipates P’s increased needs for post-operative analgesia.  The doctor also orders a wide range of non-pharmacological interventions and adjuvant medications to help alleviate P’s acute pain needs.

However, neither P nor P’s surgeon anticipate that this regimen will treat or relieve P’s chronic pain.  Following adequate recovery from surgery, P is referred back to his/her pain management specialist for long-term needs.

Sounds good, right?  Well, it should since this is the textbook scenario for patient care that has been taught in universities all over the United States for the last decade.

But this is Latin American Surgery..  so we need to explore the regulations and attitudes regarding pain management and analgesia outside of the USA.

But the very first thing people should know is: 

1.  Pain is culturally defined.

Cultural beliefs affect everyone, not just the patient..  So it isn’t just about whether the patient displays stoicism or tears.  It’s much more complex than that.   Cultural beliefs affect everyone; including doctors and nurses, so this means that culture also plays a role in pain management too…

That’s not to imply that some cultures just tell their patients “to shut up and suffer” but that pain and appropriate pain management may be viewed very, very differently depending on where the person is being treated.

In general, some cultures are more openly expressive of pain – and in these cultures pain may be treated with stronger medications and more frequently.  But that is not always the case – because the cultural beliefs surrounding pain and suffering also reflect that individual society’s belief regarding the value of suffering, as well as beliefs/ fears/ concerns regarding addiction.

Crying

Many of the cultures that are frequently cited as “highly emotive” or as cultures where pain is readily expressed are some of the same cultures where narcotics are not heavily used in in-patient or outpatient settings.

For example, many classic sociology references cite latino culture as being very expressive and emotive (ie. not stoic regarding pain).  At the same time, the use of narcotic pain medications (in my observations) are quite limited in both in-patient or outpatient settings.  Numerous medications (tramadol, ketorolac and other NSAIDS) are used to manage post-operative pain in these patients – including formulations not available in the United States.  Patients certainly weren’t undertreated:  during interviews and visits with patients, the vast majority of these patients reported good to excellent pain relief.

However, in the three years that I have been working closely with physicians in Mexico, and Colombia – I have very rarely seen a doctor order narcotics (ie. morphine, dilaudid or similar medications) on the post-operative orders.  I have never  seen a written prescription for percocet, lortab or similar medications for a patient in the outpatient setting (or as part of discharge medications.)

Obviously that doesn’t mean that these medications aren’t prescribed.  But it does show that what would be considered a routine Rx in the USA (ie. Discharge prescriptions for Percocet after cardiac surgery or lung surgery) is not routine for the doctors in the various practices that I have observed in my numerous travels.

So patients with opioid tolerance or chronic opioid use would certainly want to discuss this with their surgeons prior to surgery.

Of course, “cultural traditions” aren’t the only reason narcotics may be used / dispensed differently in other countries.  Other reasons may include:

Legal constraints / Availability

Globally, pain management practices may also be influenced by that nation’s laws as issues of supply and scarcity.  This is less of an issue in parts of Latin America but may be more problematic in Asia or other countries where narcotics are more tightly controlled.

In Mexico, for instance, many of the legal constraints for the prescribing and use of narcotics mirrors the United States.  There is a centralized governmental agency, COFEPRIS, similar to the DEA which regulates and monitors prescription drugs.  Narcotics like morphine, hydromorphone and fentanyl require a specific type of prescription called “Type 2” (and prescriptive authority for the prescribing physician).  There are dosage limitations and restrictions.  Only certain types of doctors are authorized to write these prescriptions and frequent follow ups are required (monthly) for on-going prescriptions of Type 2 drugs (A. Ballesteros, 2014).

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Happy, safe, successful travels

None of the above is to suggest that medical travel is contraindicated for American patients.  But like any big occasion or event, advanced planning is critical for a successful medical trip.

It is also a reminder to have clear expectations, good lines of communications and thorough discussions with medical providers** prior to having surgery or other procedures, particularly if you have special needs (like chronic pain management) or other health conditions.

*Venezuela is a different story. Travelers are advised to be informed, and take precautions prior to visiting this area.

** Overseas, domestic or just down the street

Additional references and resources

Vital Signs: Overdoses of Prescription Opioid Pain Relievers and Other Drugs Among Women — United States, 1999–2010.  A CDC report.

Cultural aspects of pain management.  Marcia Carteret.

Laxmaiah Manchikanti (2007).  National Drug Control Policy and Prescription Drug Abuse: Facts and Fallacies. Pain Physician, 2007;10;399-424.

Hartrick, Craig (2007).  Long term opioid treatment.  Virtual Mentor (American Medical Association Journal of Ethics).

Huxtable et. al. (2011). Acute pain management in opioid tolerant patients: a growing challenge.  Anesthesia Intensive Care, 2011, 39: 804-823.

Brafman, B (2014). Advance for nurses: Addiction in the surgical patient.

For fellow Medscape subscribers – there is an excellent series of articles as well as video lectures addressing multiple facets of the American prescription (opioid) pill problem.  I’ve included links to just a few of them here.

Managing pain

Safe prescribing

The “lessons learned” article, previously cited above.

The “Pain TV” series.

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