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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.

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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.

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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. 

  • I am a chronic pain sufferer with multiple reasons, a connective tissue disease (not EDS) similar in some symptoms to lupus, fibromyalgia, chronic fatigue syndrome, possible: endometriosis and Pcos. Due to higher amounts of women having these conditions, they are often ignored and slandered because medicine often doesn’t take chronic pain patients seriously, but it especially doesn’t take women and people of color’s pain seriously.

    I think one of the often overlooked components of the whole opiod regulatory issue is how little is done, or at least talked about, to better understand, minimize the harm, and counteract addiction as an issue. Most addicts need some compassion and sensitivity and better quality, availibility, and access to care. It is part of the conversation we need to have about mental health treatment access and quality, and for once needs to be done with sensitivity and respect for other people (otherwise you end up like the Philippines right now).

    People become physically or mentally dependant on these things- and this can be coupled with addiction because of what they are as substances and the effects they give. Most people who use pain relief of ANY KIND that works for them, especially that is chemical in nature and absorbed into the body, end up with some level of dependancy on it. To be honest I am pretty sure we would consider many schizophrenic, major depressives, ocd, and bipolar patients, etc. to be “mentally dependant” on their meds. Pain is not at same level for everyone all the time, but for many with chronic the term doesn’t mean “low-grade” it can be as bad or worse then accute pain, the term “chronic” just indicates it has gone on longer then accute pain (like a break, strain, cut, appendix removal) does.

    There is this misconception that pain meds put you in no-pain and you feel euphoric. Sure maybe to some people, a minority… Let’s be real, for example- opioid related constipation for many people is a horrible, painful problem. Opioids can make some people’s pain worse after long time use as well because of how the body processes the stuff. But the option of not taking it means not living their lives so even though the outcome may not be great they opt for it in the hopes they can keep surving like someone without their pain. Most people on pain regimines even before the further descriminatory cut backs, were still in pain even with their meds. Pain meds do not make you have super powers! The “equalize” the playing field (SOME) between someone with debilitating pain and someone without pain. The normal able person without pain can get up out of bed everyday, take a shower, feed themselves, take care of family and pets, change their clothes, brush their teeth, shave, put on deoderant, they can go to school or work or both, then at the end of the day they might be pretty tired and quite achey, especially after a full week of this… But the person with debilitating chronic pain (as lesser amounts of pain wouldn’t require opioid strength) starts the day most days *worse* than you feel when you are done your work week.

    We sometimes struggle to sleep due to our pain, when we do sleep the sleep is far lower quality, imagine having a new born baby that cries all the time. For some of us that is our normal sleep 90% of the time or more… and our only offer is to take a sleep meds that can be almost as dangerous and addictive as opioids. I literally feel pain while I sleep- it wakes me up in the night, it makes it hard for me to fall asleep. This is pretty normal for chronic pain sufferers. For some of us it is genuinely beyond moderately painful to be touched by the sheets at night, to take a shower, or to have wind blow on us (severe fibromyalgia and some other conditions, particularly neuropathies for example).

    NSAIDs are the only pain meds that have ever been offered to me in the over 5 years of reporting pain as described in this post. I have never used any drug illegally, never taken more of any prescription then I should of. From NSAIDs I developed bleeding ulcers that took 7+ months of anacids, many doctors visits, uncomfortable and embarassing procedures, and restricted diet to heal. Twice I went through this. I can not take another NSAID because my system simply cannot handle it. Many people even at recomended dosages of them or less develop ulcers and gastritis and don’t know it. You can have a bleeding ulcer and no pain, though it is uncommon. If NSAID is your prefered route, be aware of your body, don’t ignore ulcer symptoms because you are “too busy” or “can’t function enough to live without the NSAID” as I have heard many many times. Ulcers can end up life threatening.

    Also it is fascinating that chronic pain sufferers are usually the one losing out when we aren’t entirely sure how many addicts started with a prescription for accute pain rather than chronic. Or how many had other undisclosed or undertreated addictions prior. How many addicts started by self-treating mental and or physical symptoms that if treated for their addiction and given proper diagnosis and quality care would not stay actively abusing medications illegally.

    I have also heard the treatment centers most people with addiction are relegated to (not the swanky ones you see tv commercials for that costs tens of thousands of dollars) are tremendously understaffed, often have staff who aren’t fully educated, can lack compassion, and simply aren’t effective enough for many addicts to want to return if they relapse (which is pretty common. Addiction and abusive relationships have something in common in that “relapse” is part of the process for many in such terrible situations.) or to make a full and stable recovery in the first place. Mental health care needs to be better assessed, many docs practicing get away with giving subpar or negative care to their patients. Many good docs go unrecognized and if they are they end up over worked and burnt out. Facilities need to be scrutinized on some level. And of course this is complicated by so many things. Somehow we are able to hold surgeons to a reliable standard – and tho the measures may be different, we need to be able to do so with mental health professionals. Insurance companies need to be more serious about providing solid treatment for their clients. It should be illegal to deny coverage of eating disorder treatments when EDs have such high rates of tragedy, higher even than addiction.

    In my state medical marijuana has been legalized specifically to help cut back on the number of people using opioids for pain control. However one stipulation is that you try an opioid first. What? How does that make any sense? Many states who have legalized mm also deny access to people with chronic pain conditions. In fact most states who have legalized mm only do so for seizures and terminal cancer patients. In my state the smoking form isn’t legal, so claiming smoke related reasons would be silly. Oils, tinctures, edibles, pill versions- these are what will be legal once the gov gets its own dispenseries off the ground. I urge anyone reading to help push the federal gov in the US to deschedule mm from schedule 1- which is actually higher than cocaine. Descheduling or lowering the schedule of a drug doesn’t make it a free for all recreation or supplement- it allows more people to research it for one, where for years the US gov was the only institution allowed to research mm backed by anti-marijuana lobbiests. If scientists are interested in researching mm they should be able to like any other controlled substance, it could even mean coming up with a traditional synthetic pharmacuetical with benefits like any other medication.

    I also found out from my pharmacy (major pharmacy) when I ran out of my first bottle of ritalin this month, that narcotics require a new prescription each time- which means if the doctor will be writing you multiple scripts per year instead of renew-extending like some other drugs. I do wonder how this factors in with the numbers that have increased. If you look ritalin has also had a major jump with number of prescriptions made/fufillments sold in the last ~20 years.

    Also very rarely are these talked about (note: only some insurances cover them):

    Low dose ketamine infusions (also given a bad rap unnecessarily because recreationally people abuse it in higher doses in other forms as a party drug/tranquilizer/hallucinagen) – ketamine is an old med and doesn’t stand to make any pharmacuetical companies much money even for this purpose. The med itself is dirt cheap, but people must pay out of pocket thru valid doctors and clinics for the procedures (inserting the iv, observing the drip and patient) which insurance deems too “experimental”- well aren’t all meds basically experiments on people? Most anti-depressants have not been studied for long term use, nor have many other psych drugs including Ritalin which is prescribed often to children around 6 for longterm or life time use. One of the last anti-depressants I was on said in the pamphlet it has only been researched for use for a max of 8 weeks and long term use results were unknown. I was supposed to stay on this med for the the majority/rest of my life if it worked.

    Low-dose naltrexone (LDN) – most of the research has been for those with MS and it is currently being researched for many other uses for immune and pain reasons (fibromyalgia, chronic fatigue syndrome/me, others). Now you may recognize this medication if you are familiar with opioid or alcohol addiction treatment- in higher doses it has been used for this purpose for years but the high doses don’t work the way the low doses do for pain and inflammation. The studies for this are mostly funded by orgs, grants, and private donors because again it is an old med and pharmacuetical companies don’t want to foot the bill for studies on a med that won’t make them much money. (Studies cost millions of dollars even for very small studies). Now you may also of heard of a med for weight loss/control that was fda approved recently that is a wellbutrin and naltrexone compound. This however is too high a doseage of naltrexone to have the desirable effects for pain that low dose does.

    TMS (transcranial magnetic stimulation therapy) which is currently in trials and approved by some insurances for chronic pain and depression treatment. However it usually needs pre-authorization in addition to prescription and may not be fully covered for repeat treatments which many people need to extend the effects. It is done in office. Out of pocket this is quite expensive. There has also been research demonstrating that not all TMS machines are equal.

    Quell – a new device similar to tens, but it is made to be worn for longer, can be worn while sleeping, and is placed on an area of nerves that affect the whole body’s pain receptors. Some people have reported relief from it, some have tried it and not found relief. It costs around 300$ usd and isn’t covered by insurance. Most traditional tens units are not either.

    Given poor knowledge in the medical community I wonder how many people don’t get tested for rheumatological disorders that may have that can be helped at least partially by DMARDs (disease modifying anti-rheumatic drugs) such as plaquenil. Rheumatologists tend to be overly conservative in my experience for people with chronic pain who qualify for such medications. The meds when covered by insurance are usualy fairly inexpensive being that they are older well used and studdied drugs for malaria and other illnesses. Out of pocket however such meds are basically unaffordable to all but the upper middle class-wealthy.

    There are so many issues affecting the addiction/chronic pain patients like any other social issue. But a fully inclusive analytical fact based approach is rarely a part. It is mostly about money at the end of the day and misconceptions and stereotypes about marginalized and vulnerable people and less about affecting change and helping people who need it.

    For the record, I have never used opioids, but I strongly support fair reform that takes the lives of chronic pain sufferers into consideration.

  • I totally agree with this approach of treating chronic pain but insurers don’t cover some if not most multi-modal treatments. You didn’t mention acupuncture, hypnotherapy, massage therapy for example. People cannot benefit if they cannot afford these alternative treatments. I think pain management centers where all alternative therapies are made available in one location is a wonderful idea. It’s hard enough for people in pain to get around and do being able to go to one location for several different treatments would be so helpful. But if these treatments are financially out of reach then what good are they. At this point it’s cheaper for insurance companies to pay for pills and that’s what is in their best interest, not ours.

  • Just out of curiosity’s sake, would massage therapy be another example of alternative pain relief? It may work for some of those affected by opioids. It’s not covered by the government (Medicare, Tricare), but some insurance companies see different. I even saw “massage insurance” for those forward thinkers. If you give a Wounded Warrior or anyone a choice between opioids and massage therapy, I’m sure you Will have some takers, moreover, when guidelines stiffen up, massage therapy should be covered as an alternative by insurance companies.

  • Does anyone HONESTLY think you have pain, it’s tested to death, and finally declared chronic pain , and the 1st thing asked for or Rxed, is opioids?! I suppose that may be the way it works at pill mills, but I’ve never been to one. I have 2 or 3 paper charts that are 5 inches or more in size with trial and error from TENS units, to biofeedback to anti seizure meds, to chiropractic allergy meds NSAIDS, beta blockers, anti depressants, surgeries, calcium channel blockers, ergots, the option of ECT (the ONE AND ONLY THING I DECLINED), hypnosis, psychotherapy.
    And that’s just off the top of my head
    You ass docs really DO think all we are is drug seekers!

  • Multi model does not mean excluding opioids unless nothing else works, it means use of different modalities to get the whole to work-many times a much lower dose of opioids will be needed if other modalities are present. Many non-opioids are just as dangerous as opioids. NSAIDs are on the Beers Criteria as are TCA and shouldn’t be used by older adults (as well as many others-people die from NSAIDs at an alarming rate. Insurances do not pay for many non-opioids (such as the safe Lidoderm Patch) or for non-pharmaceutical interventions. Until you can get “what works for the patient” paid for, it is leaving the person with chronic pain adrift in a world of opiophobia.

  • Antiinflammatories stop the healing process and lead to chronic pain. Tylenol damages the liver’s ability to detoxify the body, leading people to more chroninc disease. There is nothing wrong with mind-body medicine, but opiates have been given a bad rap unnecessarily. They are not the cause of addiction. In fact, the use of Tylenol and Ibuprofen is more of a cause, since they cause toxification in the body. Soon I will be having webinars in the REAL cause of drug abuse and addiction. You can go to my website http://www.sevenpillarstotalhealth.com for information on when it will be available, as well as the DVD’s.

  • Yet another Dr who has no idea what we suffer with. I’ve been on both sides and am disgusted with my so called collegues behavior toward pain patients. More blah blah bs. Don’t you think we try anything and everything before pills. We hate it, but unless we want to stay bedridden, we need to take meds. Smdh

  • Congress should allocate funds for communities to offer the Chronic Pain Self-Management Workshops developed by Stanford University Patient Education Research Center. Calaveras County a small rural California offers this evidence based workshop to it’s residents for free but we struggle with funding. Empowering people with chronic pain including the community volunteers who lead the workshops is the best medicine there is. Every dollar spent on this program will save money in the long run.

  • You leave the third leg severely lacking for details. It almost seems like it was an intentional slight. Can you elaborate on what, specifically, you’re talking about there?

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