Opioid addiction, abuse, and overdose are at the forefront of our national dialogue. But by casting opioids as the villain, this important conversation is missing an essential element: how best to treat the chronic pain that afflicts 100 million Americans, including many of our wounded warriors. Chronic pain is a multifaceted problem with a range of causes and solutions, not a two-dimensional condition that can only be treated with opioids.
Last fall, while on an extended trip to Washington, D.C., I realized that the opioid addiction crisis has spawned a fundamental misunderstanding about pain management. A conversation with a senator from a Midwestern state crystallized the problem for me. When I mentioned that I ran a pain management center at Stanford University, the senator shook his head sympathetically. It’s a shame, he said, that all we can offer people in pain are addictive opioids that destroy lives.
Nothing could be further from the truth.
For people in pain, opioids are just one leg of a chair. The other three legs — which are often missing from the debate on opioid addiction — can support equal weight if the right medical expertise and infrastructure are in place.
The American Society of Anesthesiologists calls this approach multimodal analgesia. It’s the foundation for my work at Stanford Medical Center and the affiliated VA Palo Alto Health Care System, and for other pain management specialists around the country. It is also part of legislation to be reviewed tomorrow by the House and Senate Opioid Conference Committee.
For chronic pain, the first leg of the chair is nonaddictive over-the-counter pain medications, such as acetaminophen and ibuprofen. Often overlooked, these are remarkably effective for many people and can be available in higher doses by prescription. But they don’t work for everyone, nor do they provide the kind of extended relief that some patients need in order to function.
For them, an approach called neuromodulation can help. It uses a device akin to a pacemaker that is embedded in the body. The device sends electrical pulses that interrupt or mask pain signals that travel to and from the brain.
A third leg of the chair involves mind/body regimens. Once the domain of non-Western medicine, these are today grounded in abundant clinical evidence. In this approach, specially trained therapists teach patients how to live with chronic pain that is bearable but isn’t entirely treatable with over-the-counter medicines or neuromodulation. Commonly used mind/body techniques include cognitive behavioral therapy, graded activity and exposure therapy, and biofeedback.
Only when these approaches have been exhausted should opioids be considered as a treatment option.
For a fraction of the cost required to further regulate opioids and enforce new national rules, we could create pain management centers around the country and make sure that their medical teams adopt integrated, multimodal approaches to treating pain.
By diversifying the approach to pain management and educating the public — and doctors — about alternatives to opioids, we can keep many people from needing them in the first place and lower the risk of addiction for those who must rely on these drugs. By using the options we have more wisely, the prognosis for chronic pain isn’t as bleak as many people, like the senator I spoke with, believe.
Michael Leong, MD, is clinical associate professor in Stanford University Medical Center’s department of anesthesiology, perioperative, and pain medicine and former clinic chief of the Stanford Pain Management Center. He has received payments from St. Jude Medical, Boston Scientific, Stimwave Technologies, Mallinkrodt, and Jazz Pharmaceuticals.
This article was edited to update the author’s disclosures.
Also, the extensive conflicts of interest regarding medical device manufacturers ruins the authors credibility when recommending neuromodulation
People take hardcore painkillers not cause they want to but cause they have to from severe pain that is so bad they want to die.
Thank you, Dr. Leong, for at least acknowledging that there are patients with incurable lifelong disease who have exhausted all alternative treatment options. We have already been through years of harrowing invasive treatments and therapy at multimodal pain centers. We exist, and we matter too.
I had major necrosis at the head of the femur, with abrasive and bone graft attempts at revascularization. That failed, and I’ve had six additional surgeries in that knee since. Deep family history of both osteo and autoimmune arthritis (100% of at least 3 generations on father’s side had multiple joint replacements in early/mid 50’s. Multiple laminectomies L5/S1, 4/L5; multiple stenosis surgeries 5/S1. Surgeries repairing 3 torn ligaments in ankle and 3 in shoulder. 4 RFA
I’ve done mind/body (both active visualization and biofeedback), mindfulness work (numerous focus activities daily), cognitive behavioral therapy (with occupational/pain focused psychologist), OTC analgesics, TENS (both to interrupt pain signals and help keep muscle tone in areas where exercise is limited), autoimmune arthritis (ankylosing spondylitis) prescription therapies, acupuncture, massage, applied heat, and prescription pain meds (opioid, gabapentin, cymbalta). My pain treatment chair has had four legs and a spare since 1994. I’ve never increased my pain meds once identifying a level that was therapeutic- that is, that allowed me to do SOME of the many things I’d done before. Every quarter, I have “pain week”, where I reduce my opiate dose by half every other day to 25% of normal dosage, remain at that level for several days, then reverse the process, increasing only as much as seems absolutely necessary, not to exceed the original dosage. This helps to let tolerance buildup, and allows me to avoid increasing dosages. I’ve been doing this since 2006.
Who cares, everyone has a story, right? My point is that I’ve always done everything I can, not just take opioids. In fact, from 1994 – 2003 I refused to take opioids despite recommendations from each of the ortho, rheumy and pain docs I saw. It was only after nearly ten years of decreasing function, increasing pain, horrible sleep (constant awakening due to pain, extreme difficulty falling asleep, very little REM or deeper sleep per sleep study), when I began seeing an impact on my ability to work, that I accepted opioids as part of my program.
Still, despite a long (15 years) history, always prescribed by my primary care doc, always filled at the same pharmacy, never having lost or had medication stolen, always testing appropriately in urine tests (semiannual testing from 2006 to present as part of a chronic pain management plan), never having taken more than prescribed, etc., it’s a real pain in the ass to take opioids at all. I spend part-time with my kids and part with my parents who are getting older. I have to see my PCP every month to get a written prescription. I plan my time around seeing her, and God forbid if an emergency, bad weather or whatever, cause me to be away longer than 30 days. If that happens, you just run out. You can imagine how fun that would be after 15 years of taking the opioids and building physical dependence as the relevant receptors are changed by it. When I’m in town for my appointment, I must carefully review the physical printed prescription. Any omission, inconsistency or error – material or not, means the pharmacy won’t fill it. And a phone call won’t fix it. It requires me to return to the Dr office, point out the issue, get a corrected prescription, sign a form acknowledging that I won’t sell, abuse or lose the prescription, then return to the pharmacy. Many pharmacies simply refuse to fill opioid prescriptions. The closest one I’ve found to me is 30 minutes by car. I live in a major metro area. State regulations, federal regulations, insurance and pharmacy company procedures, and the opinions of the pharmacist and techs all affect how the prescription is processed, how late by it takes, and whether it is filled when presented, a day or two later, after getting a new prior authorization from the Dr who just wrote the prescription, and has been both prescribing the med, and filing annual preauthorizations for the past fifteen years. Unless I remind them that I’m a long-established patient, my pharmacy will automatically tell me the prescription will not be available for 24 hours. It requires extra “processing”. Then, when I tell them, and they look up my history, they fill it without the extra processing – whatever that is. Any change (say, from taking 2 10mg pills a day, to taking 4 5 mg pills a day, will freeze the process until the Dr authorizes the “new dosage”. You’ll note that 4*5=20, and 2*10=20. It’s the same dosage, simply different pill denominations. This was so I could try taking 1 in the morning and two at night, to see if I might reduce how much I took to 15mg. But the max was still 20. Yet I had to wait Friday to Monday afternoon to have my prescription filled, waiting for the Doc to preauthorize the prescription she’d just written).
There are literally dozens of disincentives to taking opioids. I live with debilitating pain. I seldom leave home, have trouble with basic chores like laundry, cleaning. Once an amateur chef who loved cooking, a white water raft and kayaker, hiker, basketball player, baseball/softball player, youth coach, senior executive in an international corporation, founder of two startups, skier, cross country skier, scuba diver, author…well, I hope that gives an idea; I was once a very, very active person. As I’ve lost function (and will continue to do so), and pain became more widespread, the impacts on my life have increased space. I now stay in a “zero gravity” position 16-20 hours a day. I use every tool mentioned above, many times a day. I hover between 7-8 in terms of pain (I’d never reported more than 6, even immediately after surgery, until about ten years ago). There are times where I can do nothing more than lie on the very hot floor of my metal tub, trying not to twitch. Both hands are partially numb (can’t feel texture, really anything but pressure doesn’t register), the spurs in my feet make it brutal to stand. I’ve had iritis episodes twice (the autoimmune inflammation targets the eyes), and those episodes cut my vision in half. A lifelong bibliophile with a library of 1500+ books,and having read many more, I read no more than an hour per day, to avoid eye strain. I do listen to books on tape, and thank God for YouTube Amazon, Netflix. Etc.
My quality of life is extremely low, but I’m not depressed, isolated, hopeless, etc. I make the best of it day to day, and use every tool as best I can to live as well as I can. Have 4 legs on my stool, and have been working on adding those legs for far longer than my docs have been recommending them (and I have very good docs). Somehow we’ve gone from “pain is a vital sign” to “drop opioids, practice mindfulness” in a decade. I was concerned in 2003 that opioids were being prescribed with minimal other therapies – sometimes PT, often not even OTC. Now I’m concerned that a very real, fire, important problem which we must do something about – the opioid abuse and overdose crisis, is overshadowing medical care for patients like me. Patients who have done everything they’ve been asked, have sought every complimentary and ancillary tool available – and practice them daily. Patients whose function is diminishing, whose attendant pain is increasing. Ten years ago the docs asked about, probed, discussed pain and what our options were. Today, it’s a number on a chart. My docs don’t talk about it, don’t discuss options. I’ve a long history, and a long record of careful adherence to prescription. A long history of using every tool – often found through my own research and the online support group I founded. I’ve introduced medical equipment to a well-known pain specialist, who prescribed it now (after carefully doing his own research).
In time, I’ll be in a wheelchair all the time. I’ll likely have more joints replaced, more surgeries. I’ll practice all the tools I have and look constantly for more. And I’ll keep taking a sub-therapeutic dose of opioids, hurting a bit more every year. And until the medical and government community can bring some balance back to this subject – bring out some sound medical program for folks like me, who won’t get better, will get a bit worse every year, may hurt a bit more with it.
On an average month I make two trips to my PCP, four half hour drives to my pharmacy, make a call or two, hear a snotty drug addict remark or two, and have my schedule of time with kids and parents governed by the 30 day cycle of prescription and filling same. It takes an average of five hours, every month, along with anxiety every month about possibly facing physical withdrawal pain.
At the least, I ought to be considered as a person, with an established history of doing everything I’m asked to treat my problems, and more, or never abusing or misusing my meds, and always going to pains to follow every rule. I’m not the addict, abuser, deceased OD victim. All I want is to be treated for MY circumstances, not the pattern that is scaring the shit out of everyone and ruining lives at a horrendous pace. I’m not asking for any more than to have my medical and personal history evaluated on its merits, and my medical issues addressed just according to me, and not some conflated average somewhere that basically has ensured that I’m not being treated like a patient but a statistic. I’m a patient. A good, responsible patient. Please treat me as such. Help me use every tool I can go keep as much fading life quality as I can.
Thank you for sharing your amazing, personal story. I can relate to so much. You are not alone in the struggle. If only more clinicians understood these issues at this level of detail. Peace and love to you!
I take a 50mg fentanyl patch every 3 days and a backup of morphine 15 mg 3 times a day because the fentanyl patch only lasts a day maybe two and the doctor tells me is because my tolerance on the fentanyl has gotten so high that it has become ineffective the only thing that does work is that fentanyl patch it gives me at least one day out of three where I can really get out of bed and have some quality of life now he wants me to go on Suboxone for pain I’m wondering if that’ll help also my pain is Chronicle abdomen pain due to ulcerative colitis where I had my whole colon removed and after having my my colostomy bag reversed and having chronic diarrhea on a daily basis anywhere from 10 to 25 a day for the last three and a half years the pain is also a lot more worse which I contribute to that also I think I have inflammation of the small intestine and I also have pancreatitis I also have sciatic back pain which occurs approximately every 6 months attacks up and I was just wondering is suboxone the way to go or what do I do
> Only when these approaches have been exhausted should opioids be considered as a treatment option.
Good. When you have a medical problem, I’ll shove a cattle prod (i.e. your implant) in you. Only when that doesn’t work (and you pay for it) and suck up the risks will other therapy be made available to you. YOU are the reason people go on heroin.
Sounds good in theory, but have you been laid out in such pain you couldn’t move or sleep. I have been suicidal Amen brother
Targinact gabapentin etc fentynal patches had the lot age 84 widow walking sitting even in bed pain down backs of legs just wish I could leave this world behind. there is no quality in life for me my daughter died alone in Arizona polypharmacy killed her. They say I am too old to have the pain relief inserted