Ricardo Gonzalez
ID: L31156909
September 23, 2021
Journal Entry: Medicine
Liberty University
Master of Arts in Medical Sciences
MSCI 640-B01
Introduction
This week’s content really brought front and center one of the biggest issues plaguing the
United States: the opioid epidemic. And also the idea and issues behind socialized healthcare. In
their manuscript on Opioids and the Treatment of Chronic Pain, Rosenblum and colleagues do a
great job of illustrating both sides of the argument. I work in a pharmacy where we dispense
medications like oxycodone and hydrocodone regularly. From my personal experience, some
physicians have been treating chronic pain patients the same way for years. When referring to
this prescribing, I mean chronic non-malignant pain (CNMP) patients diagnosed with
idiosyncratic pain, unidentified cervicalgia, or some form of spondylosis. Now I am not saying
these are not legitimate diagnoses that warrant the use of an opioid. Still, my main concern is
that after many years of opioid use when no other avenue was explored is just unjustified and
makes the patient an addict. In my personal experience working at a pharmacy for the past six
years, I have witnessed only a handful of patients ween off their opioids and pursue other
alternatives. This leads me to believe that physicians are not actively looking for ways to not
only really get to the root cause of the pain, but they do not seek other options besides
prescribing opioids. However, there is another side to this, and this falls on the actual patients
themselves. I had a patient with unexplained chronic cervicalgia. His PCP would no longer
prescribe him opioids for pain because he wanted to ween him off. After all, it was becoming a
terrible addiction. This patient stopped going to his PCP and went practically “Dr. shopping,” as
he called it, until he found a physician willing to prescribe him opioids for the pain. At this point,
it is tough to distinguish if this patient is addicted or is in such severe pain. I do not think the
answer is black and white because pain is relatively subjective. Historically opioid stigmatism
has led to the underutilization of these types of medication for pain relief because of addiction
concerns.1 Now, before we continue on our discussion, a brief overview of the mechanism of
action of opioids must first be described to understand its physical and medical implications.
The primary mechanism of action of opioids occurs when the drug is ingested. It will then bind
to specific proteins known as opioid receptors. These receptors are dispersed throughout the
body, with the pain modulatory regions being localized to the central and peripheral nervous
systems.1 These same receptors also bind endogenous opioid peptides, which are a part of pain
modulation, modulation of reinforcement, mood, and reward mechanisms.1 After an opioid is
administered, analgesia may ensue; however, it may cause reduced peristalsis, itchiness, miosis,
mental clouding, and respiratory depression.1 This is caused by the secondary effects mediated
by activation of these receptors by the CNS and PNS. These central mechanisms have also been
described by changes that induce hyperalgesia and a decrease in opioid responsiveness.
However, concomitantly these receptors are also involved in reinforcement and reward. There
can be powerful reinforcement that can gradually occur with opioid usage because chronic is
associated with craving and positive mood effects such as euphoria, which can occur in the
absence or presence of actual pain.1 The literature says this is uncommon unless there are
genetic risk factors or associated with iatrogenic addiction. Nonetheless, repeated exposure to
pharmaceutical activation of a drug that can activate a euphoric experience will only induce
craving physically and psychologically. The most harmful and most effective opioid drugs are
those that are mu agonists. They fully activate opioid receptors and produce the most analgesic
and reinforcing effects.1 These include morphine, methadone, and oxycodone. The opioids that
occupy but do not activate are known as an opioid antagonists. They reverse the effects of an
overdose. In the pharmacy, we also have one in case of an emergency. They are also the only
medication that pharmacists can prescribe in the state of Florida. The text made an important
distinction between tolerance and physical dependence that must be noted. Tolerance refers to
a decreased subjective and objective effect of the same amount of opioids used over time.1
Whereas, physical dependence is a characteristic set of signs and symptoms associated with
opioid withdrawal.1 Tapering down of an opioid will typically help a patient not experience
symptoms. Addiction is defined as a chronic disease that is an idiosyncratic adverse reaction to
psychologically and biologically vulnerable individuals.1 The text points out that patients with no
history of opioid abuse would theoretically respond better to treatment while minimizing
problematic behaviors associated with addiction. That, however, does not account for patients
that started with pain then ended with pain and addiction. This debate is not black and white
because pain is physiological and psychological. I believe that acute use will eventually turn into
chronic abuse. From personal experience, I know from multiple patients who get their pain
medications three days early that the state can dispense. This leads me to believe that yes, they
are in pain, they have a physical dependence, and yes, they are addicted so much that they
could not wait the extra three days to get their medication. What I do not see is their pain
specialist changing therapy or trying other alternatives. I am all for the use of opioids to treat
pain as an acute option, as a starting point, as a temporary fix. I am against overprescribing
opioids, increasing doses for long-term use, and not to mention they do not even prescribe
naloxone spray. Every patient on opioids should receive Narcan because it will save a life in case
of an opioid overdose. Just to put it in perspective, deaths related to opioid overdoses jumped
last year to 93,000, an exponential increase from the previous year.4 1 Peter 5:8 Be sober-
minded; be watchful. Your adversary, the devil, prowls around like a roaring lion, seeking
someone to devour. May we look to our Lord and Savior in times like these when addiction is so
prevalent in today’s youth.
The discussions this week focused basically on spirituality and its place in healthcare. There was
a consensus among us that there is room for all three modalities to treat illness. Pastoral care
and praying seem to work in tandem. I agreed that the point of praying is not to seek a cure but
to ask for guidance in times of crisis. The real miracle discussed is not the quadriplegic standing
but them accepting our Lord and Savior when she cannot stand. In my research, something
stood out to me, Victor Frankl, a psychiatrist in a Nazi concentration camp, wrote, “Man is not
destroyed by suffering; he is destroyed by suffering without meaning.”2 It was not finding
meaning and acceptance that destroyed people in his belief. I would agree with that; it is the
meaning of life, finding acceptance in spirituality. It knows that there is an end that makes
everything worth fighting for; we will return home to the kingdom of God. John 18:36 Jesus
answered, “My kingdom is not of this world. If my kingdom were of this world, my servants
would have fought that I might not be delivered over to the Jews. But my kingdom is not from
the world.”
The next topic that was reviewed was the idea of socialized healthcare. In theory, socialized
healthcare sounds impressive, but it is justified in the United States in practical terms. The
United States by far spends more money on healthcare per capita than any other country in the
world. Which that being said would that be economically viable? That means there would be a
massive hike in taxes for the individuals and families that might not be feasible. The positives
would be the millions of individuals that cannot afford healthcare would finally be able to.
Countries that have employed this would include Turkey; in 2005, they launched the Family
Medicine Program (FMP) that assigned each citizen to a specific state-employed physician that
offered a wide range of services.5 While this program was introduced, the country observed a
decrease in mortality rates, especially among infants and the elderly. The FMP saw a 25.6%
decrease in infant mortality rates and 7.7% amongst the elderly.5 There is evidence that this
structure works. However, our per capita expenditure on healthcare heavily outweighs Turkeys.
So the question here is not whether or not this structure works. It is whether or not it can be
sustained monetarily.
References
Carroll, R. Bible-kjv. Oxford University Press, USA. 2008
5. Cesur R, Güneş PM, Tekin E, Ulker A. The value of socialized medicine: The impact of universal
primary healthcare provision on mortality rates in turkey. Journal of Public Economics.
2017;150:75-93. https://www.sciencedirect.com/science/article/pii/S0047272717300506. DOI:
https://doi.org /10.1016/j.jpubeco.2017.03.00
1. Rosenblum A, Marsch LA, Joseph H, Portenoy RK. Opioids and the treatment of chronic pain:
controversies, current status, and future directions. Exp Clin Psychopharmacol. 2008;16(5):405-
416. doi:10.1037/a0013628
2. Puchalski CM. The role of spirituality in health care. Proc (Bayl Univ Med Cent).
2001;14(4):352-357. doi:10.1080/08998280.2001.11927788
3. Abuse, National Institute on Drug. Overdose death rates. National Institute on Drug Abuse
Web site. https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates.
Updated
2021. Accessed Sep 26, 2021.
4.
