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 (BSX), Stimwave Technologies, Mallinkrodt, and Jazz Pharmaceuticals.
This article was edited to update the author’s disclosures.