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Responsibly and Sensitively Addressing Chronic Pain Amid an Opioid Crisis

September 02, 2016

image of stethascope and prescription pad

Last week, the U.S. Surgeon General, Vivek Murthy, sent a personal letter  to more than 2.3 million health care practitioners and public health leaders, seeking their help to address the prescription opioid crisis. He called on physicians to educate themselves in appropriate prescribing of opioids, to screen patients for opioid use disorders and refer them to treatment if necessary, and to set the right example in talking about addiction as a medical illness and not a moral failing. The Surgeon General’s letter is an important acknowledgement of both medicine’s responsibility to lead the country out of the current opioid crisis, and the mistakes that medicine and the healthcare system made in the past, which helped bring us to this point.

Medicine is not perfect. Guidelines and practices that make sense at one point in time, often based on the best available evidence and theory, are frequently reversed when better data emerge—and sometimes only after patients have been harmed. A recent analysis of articles in the New England Journal of Medicine from 2001 to 2010 identified 146 reversals of recommended medical practice during that decade alone. The increased aggressiveness in treating moderate acute and chronic forms of pain using opioids during the 1990s, abetted by heavy marketing of these drugs, will undoubtedly go down in history as another of those failed strategies, whose reversal we are now seeing in revised pain management guidelines such as those released by the CDC this past March.

Although the exact numbers are not known, the majority of people with opioid use disorders are not pain patients and did not start that way. However, overprescribing of opioids in clinical settings made these drugs available in large quantities for diversion and misuse; and there is growing evidence that treating certain kinds of pain (both acute and chronic) with opioids can have the unintended effect of worsening it for some patients. Recent studies are shedding new light on why using opioids to kill pain in the short term can have the paradoxical effect of actually intensifying and prolonging pain—an effect known as opioid-induced hyperalgesia. For example, a recent study using a rat model of chronic nerve pain found that morphine significantly enhanced sensitivity to pain following injury and prolonged the pain of the injury well beyond the point at which the tissues had healed; the priming of glial cells in the spine by inflammation may be why. The risk of hyperalgesia is another reason, besides addiction risk, that the CDC is now counseling less reliance on opioids for management of chronic pain except in cancer pain and palliative care.

It is particularly tragic that these lessons about opioids—both their addictiveness and their ability to actually increase pain—were learned as much as a century and a half ago but were forgotten or ignored. In the late 19th and early 20th century, widespread sale and medicinal use of opioids like morphine, heroin, and opium (as well as other widely misused pharmaceuticals like cocaine) led to increased misuse and addiction. Early drug policies in America, like the Harrison Narcotics Tax Act of 1914, were designed to address this problem by restricting and regulating the sale and prescribing of habit-forming substances. What is not as widely known is that increased pain sensitivity as a result of opioid dependency, then called “morphia,” was also described in the medical literature as early as 1870.

Given what we are now learning about opioids’ paradoxical effects, one has to wonder whether overtreatment with opioids might have contributed to the rise in chronic pain in America instead of just treating it. Without better epidemiological data on pain trends over time, it is only possible to speculate. The United States consumes the vast majority of the world’s opioid medications, and pain prevalence in the United States is higher than in most other developed countries. The rise in opioid prescribing, especially since pain was declared the “fifth vital sign” in 1996 (the same year OxyContin was approved), paralleled a rise in diagnoses for common forms of pain including chronic low back pain. But it is hard to disentangle these trends from other contributing variables like increased obesity in the U.S. population, which can also increase pain, as well as the increased survival from chronic diseases that produce pain. Future research will need to closely examine these questions.

In any case, people with chronic pain are real victims of these shifting tides of medical practice, and we cannot forget about these patients in our haste to end the opioid misuse crisis. Health organizations are now taking steps to revise how we diagnose and manage pain in this country, but as yet, medicine has little to offer chronic pain patients in place of opioids. Many patients with chronic pain are understandably concerned that the only medications that give them some relief are less and less available to them, and they complain of being stigmatized as “addicts” because of the almost inevitable physical dependence that comes with long-term opioid treatment, which is frequently confused with addiction. Physicians must understand that dependence on opioids is not the same as addiction; and the potential dangers of restricting opioid medications on which patients are physically dependent could be devastating in the current drug landscape, where counterfeit pain pills made with the very potent opioid medication fentanyl are causing overdoses and claiming many lives.

The Surgeon General’s letter is a call for physicians to assume greater responsibility in addressing the opioid crisis. Responsibly addressing pain includes treating existing pain patients with sensitivity and care, understanding the difficult nuances of opioid tolerance and physical dependence and their distinctness from opioid use disorders including addiction, and following appropriate strategies for addressing hyperalgesia. It is also incumbent on researchers in our field to redouble our efforts to search for new pain medications (and non-drug treatments) that have less misuse and dependence liability. Similarly, insurance and health care providers need to cover and offer evidence-based alternatives to the management of chronic pain even when they are more costly than opioid medications. Safe and effective pain management needs to be a top priority for researchers and for the health care system.

This page was last updated September 2016

Comments

State of Connecticut 2016 Legislation to Address Opioid Epidemic

The Connecticut Association of Addiction Professionals worked with state legislators, behavioral health providers, criminal justice leaders, and most importantly, individuals struggling with opioid addiction to pass Section 6 of the comprehensive 2016 Opioid Legislation. The policy recommends the collaboration between licensed addiction specialists and PCPS to offer prevention and early intervention services to patients exhibiting early signs of dependence upon pain meds. In the context of a medical visit, patients will be referred to the addiction specialist for diagnosis, referral, and TX, as needed. The referring PCP will receive a consult note from the addiction specialist that will be reviewed by the
physician and patient for appropriate Tx for pain management.The legislation, as the Surgeon General recommends, provides an enlightened and effective public policy ,that treats opioid addiction as a Disease- thus reducing the powerful obstacles of Shame and Stigma associated with active addiction,

Susan Campion LADC, LMFT
President, CT Association of Addiction Professionals

Opiates

I had total hip replacement surgery 2005. This surgery changed my life in two very different ways. While ecstatic to walk without pain and a severe limp I abused the oxycodone I was given for pain management. What followed was years of addicton to painkillers eventually evolving into a heroin addiction. I was given 100 5mg oxycodone pills when I was discyarged. I ask for and received 3 or 4 more refills. I think that amount is excessive now that I am in recovery. I am one of many addic5s who abused pain meds and then abused herion. I am clean 5 months. I have educated myself about addiction and the brain. I thank Dr Volkow for her dedicaton and commitment to helping addicts like me.

Benzos and Opiod pain medications

There should be very strict guidelines for prescribing the opioid medications and benzos. It is very dangerous. Doctors should be trained in addiction.

Chronic Pain Patients Denied Medication

I've been a Chronic Pain patient since 2003 due to failed back surgery that left me with damaged nerves and pain that is constant and relentless. You may look at the prevalence of back surgeries, hip and knee replacement surgeries as other reasons for the increased use of opioids in US. Not all these procedures are successful. I've been on the same dosage for the past 6 years and it allows me to have a life and not be confined to my home. Fentanyl patches for me have been a lifesaver. I'm not craving more medication, do not doctor shop. I've read where chronic pain patients have been taken off opioids or cut back with no help in dealing with withdrawal. This seems to be happening to VA patients especially. How can this be legal or ethical? I thought doctors took an oath to cause no harm!

It seems the "War on Opioids" is causing great harm to chronic pain patients that need these medications. I understand that there is an addiction problem in US but to balance it on the backs of people who are already suffering greatly and taking away their medications makes it seem that addicts are more important than chronically ill people, who in no way asked to be in this position. There are people in pain committing suicide because of these new policies. Is the idea to rid America of people suffering from chronic pain conditions?

New CDC guidelines

I had stomach surgery 11yrs ago that went vert wrong. Had gastrict Bypass! My stomach never healed right. My body developed an abscess due to a hole when Dr punctured my Esophagus. Every time I wd eat or drink food went out the hole &into the abscess. The abscess lays on my diaghram that causes severe residual pain in my neck &shoulder. I've been hospitalized just about every YR since. I get temps often due to other issues it has caused! I have developed arthritis all over due to lack of nutrition, & upper n lower back problems.
I've been hospitalized 3times for GI bleeds!!
I cannot take NSAIDS!! For the last 4years I've been seeing the same pain clinic, receiving the same dose of morphine! I get pee test done every month, never any problems or questions. The Drs tell me I'm such a good patient &they wish all their patients were as honest as me and so forth!! The pain medsI dont take all of my pain away. But it certainly helps!!
They now tell me about the new guidelines &as a group of Drs in their practice they will only prescribe 100mg per month to their patients. I was on 180mg of morphine ER. I've been weened down to 120mg and every day I'm in tears. The pain is excruciating. I just found out I have arthritis in my hips. I was never aware of it as I was taking the right amount of morphine.

Opioid Abuse

I just found out my sibling died of an accidental overdose of fentanyl. My guess is he got it off the street. Sadly, this is the hardest area to control. :(

War on pain patients

Perhaps you are well meaning, CDC, but you are truly out of touch with reality. Patients should just suck it up and accept pain as a way of life? I would like you all at the CDC to become the pain patients and realize the outcome of your misguided BS. It is likely that my wish will partially come true as a significant percentage of you are likely to be in that position to be the patient. The more effective your policy, the less likely your pain will be treated. Instead, we will not sympathize when you are told to "manage your [own] expectations" of what pain treatment can accomplish. Take a few deep breaths and think about how those NSAIDs and behavioural psycho babble is woking next time you get hit by a bus!

Actiq and Fentanyl use

I was given Actiq for breakthrough pain and Fentanyl patch 50mcg following cancer (stage 3c) treatment where I has severe side effects to chemo and radiotherapy. Obstructed bowel (multiple) had my small bowel removed and on parental nutrition. Multiple pulmonary emboli, on going bleeding from bowel and bladder, pelvic radiation disease, compression fracture in 3 vertebra and sciatica, lymphedema in leg toe to belly button. After 3 years there is a sudden drive to get me off this drug as I have survived my cancer. Little help was given. I devised my own taper programme 8 weeks for the Actiq and 12 days for the patch. Yes I suffered withdrawal. The pain team that prescribed these drugs offered no help. I'm still waiting on my appointment with them.
Too little is done to support individuals like myself. Given my complex problems I should have been given in patient treatment rather than suffer the dehydration I did from side effects. When will doctors ever learn. I hope no one else suffers like I did.

FENTANYL DEATH

Isn't it remarkable that one of the main objections to medical marijuana is edible gummy bears
which have NEVER killed ANYONE, while deadly fentanyl lollipops are still marketed?

Candy amphetamines (adderall) are also on the market, but they get no air time either.
Cannabis gummies. One of the biggest flags being waved by anti-cannabis propagandists.
UN REAL

Chronic uncurable pain

Chronic uncurable pain, for example painful peripheral neuropathy must be treated. Since there is no cure or effective treatment except opioids what should one do? Contract cancer? I remember the day I was diagnosed, the neurologist said " I am so sorry" without further explanation Subsequently a host of mind numbing tri cyclic anti depressants, neurontin, completely disabling medications that were very ineffective at controlling pain were endured. Finally a UC pain clinic, Perscribed MS Contin, a sustained release form of morphine. Finally after 5 years some relief. I have been on the exact same dose for 15 years. Worried about addiction I have purposely stopped treatment to see what happened, only more pain in feet. No other symptoms from stopping 90mg per day.
I am now on a fixed income of SS. Yet narco fanatics increases my dr visits to 12 specialist per year, a huge expense. Now they are threatening even tighter restrictions, in spite of evidence that increased restrictions correspond to increased overdoses. Idiots!

I have never used any illegal drugs and will not. However if I hade the constant pain I was enduring without the MS Contin I would, most likely, do anything to stop the pain I hope to never face that choice. Listen to those that lost pain relief and paid with their lives. OD may or may not have been a choice, but the illicit drug dealer has home delivety,.the legitimate drugs require jumping through many hoops, with more being added.

Torturing Real Pain Patients

Patients who have surgery, any kind of surgery should not have to endure severe or even moderate level of post-op pain because of abusers. Patients with honest pain producing conditions should not be tortured because of abusers. It seems to me that patients are paying the price for abusers and bad prescribing practices. Have an allergy to NSAIDS too bad, suffer you must be an abuser. Hip replacement, 10 days post op too bad deal with the pain you must be a drug seeker. The Science of Medicine should not be knee-jerk. With all of our ability to link charts and prescriptions one would think we could use our heads and be compassionate to those in need and cut off those not in need.

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