attling opioid abuse is a public health imperative. But this worthy effort must not sacrifice the health and quality of life of the millions of Americans who suffer from chronic pain.
There’s no question that we are in the midst of an epidemic of the misuse of opioid pain relievers such as oxycodone (OxyContin) and hydrocodone (Vicodin). Since 1999, sales of prescription opioids have nearly quadrupled. During that same period, close to 200,000 Americans have died from overdoses of opioid pain medications, and such overdoses account for more than 400,000 emergency department visits each year.
Opioids are highly effective medications for treating cancer-related pain or pain at the end of life or after major surgery. For long-term pain caused by chronic conditions such as osteoarthritis or back pain, however, the Agency for Healthcare Research and Quality says the overall evidence for the effectiveness of opioids is low. Evaluating the trade-off between benefit and risk is always complex, and, in the context of opioids, one-size-fits-all policies probably won’t work. Yet that appears to be what the Centers for Disease Control and Prevention offer in guidelines it released in mid-March aimed at helping primary care clinicians prescribe opioids in situations other than cancer treatment, palliative care, or at the end of life.
Chronic pain is an amorphous beast. Chronic pain from nerve damage is not the same as chronic pain from a knee injury; chronic pain from multiple sclerosis is not the same as chronic pain from sickle cell anemia. Pain is individual, subjective, and nearly indescribable. Sometimes it doesn’t appear to be related to any sort of physical injury, leading some physicians to consider it to be a sign of psychiatric problems or outright pill-seeking to support an addiction. Chronic pain is sometimes stigmatized, especially when there is no visible cause. This can lead to problems related to work and school, and even to being ostracized by friends or family.
If left untreated, undertreated, or mistreated, chronic pain begets its own disease problems. It can disturb the heart rate and blood pressure, throw off balance, and result in functional changes in the brain. Pain gets “encoded” in the body, sensitizing the nervous system to experience pain even if the initial source of the pain goes away. Such “phantom” pain hurts as much as any other.
Being in pain is not merely a matter of being uncomfortable. Pain makes living difficult, and can make any physical activity — working, exercising, visiting a therapist, or cooking a healthy dinner — challenging and sometimes impossible. And, of course, pain affects people mentally and emotionally.
How best to treat chronic pain is something of an open question. Opioids quell chronic pain, but their effectiveness fades over time, requiring higher and higher doses to be effective. The longer they are used, the greater the chance of addiction.
We need to find ways to treat chronic pain without putting people at risk for opioid addiction. One important step is gaining a better understanding of chronic pain. Another is promoting wider use of nonaddicting medications, such as nonsteroidal anti-inflammatory drugs and antidepressants, which can sometimes be appropriate alternatives to opioids. The continued development of new non-opioid options should also be a high priority.
Non-pharmaceutical approaches to relieving chronic pain such as cognitive behavioral therapy, exercise therapy, acupuncture, biofeedback, and the like are helpful for some individuals. Sadly, many Americans can’t access or afford these treatments. Not all health insurance plans cover such interventions, and not all health care providers are willing to prescribe them to their patients.
A total war on opioids isn’t the way to solve the epidemic of overdoses. We need a multidisciplinary effort to tackle this problem, which will take time, money, and numerous dedicated investigators and patients to figure this out. Until then, we should not say that only individuals getting palliative or end-of-life care or being treated for cancer “deserve” access to opioids.
The sweet spot for controlling chronic pain means decreasing the number of opioid medications physicians inappropriately prescribe without harming patients who, for lack of other available, effective alternatives, rely upon them for relief of chronic pain. How do we manage to hit that balance? Some good ideas already exist. A number of states have prescription drug monitoring programs that track how often a patient is prescribed controlled drugs, thus allowing for the identification of health care providers who overprescribe. Other tactics that discourage overprescription from so-called “pill mills” include requiring all facilities providing opioid prescriptions to outpatients to be owned by a physician or to be registered with the state. A different approach that may be useful is to encourage primary care physicians to refer patients with chronic pain to clinicians with expertise in this area and to increase physician education about best practices for using and prescribing opioids.
We must strive to prevent losing lives to opioid abuse. At the same time, we should not categorically deny opioids to those who have tried other treatments with no effect and who rely upon these drugs to work, study, or experience active, whole lives. It is inhumane to sentence them to lives of pain.
Alison Bateman-House, PhD, is a postdoctoral fellow in the Division of Medical Ethics at New York University Langone Medical Center. Arthur L. Caplan, PhD, is professor of bioethics and founding director of the Division of Medical Ethics at the New York University Langone Medical Center.