T

he opioid epidemic has rapidly emerged from the shadows and is now recognized as a plague that affects hundreds of thousands of Americans regardless of age, race, or socioeconomic status. In its destructive potential, it can be compared to the AIDS and polio epidemics. But unlike AIDS and polio, the opioid epidemic continues to rage in large part because we, as a nation, have not yet resolved to attack it head on.

As highlighted in the surgeon general’s report released this week, “Facing Addiction in America,” we are now beginning to translate rhetoric into national initiatives that target community-based education, treatment centers, and interventions to stop the distribution of opioids and to implement effective treatment and prevention programs. As the report emphasizes, those afflicted need insurance coverage as well as resources for education and treatment, which will certainly lead to new federal initiatives and financial outlays.

The surgeon general’s recommendations represent a major step forward in our fight against this deadly scourge. Like most epidemics, the immediate call to arms by our federal agencies is focused on helping those who are currently affected by opioid addiction and implementing steps to minimize the risk for addiction and death in vulnerable populations.

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Yet the call to eliminate the use of opioids for chronic pain represents a major dilemma for health care providers and their patients because we are also facing an epidemic of chronic pain. As documented in the 2011 Institute of Medicine report, “Relieving Pain in America,” more than 100 million Americans suffer from chronic pain. It costs our society a staggering $600 billion a year. That is more than we spend each year on treating cancer, heart disease, and diabetes combined.

Many, but certainly not all, patients who suffer from chronic pain rely on legally prescribed opioids to live, work, and function in their daily routines. For them, opioids are among the few therapies that work.

How do we decrease addiction to opioids and still humanely and ethically treat the millions of Americans suffering from chronic pain? As a pain expert, I had hoped the surgeon general’s report would have placed a greater emphasis on the need to develop alternatives to opioids that can be used for pain management, which would eliminate a key pathway to abuse.

Although the president, Congress, and federal agencies are making substantial headway in funding educational and treatment programs, they have fallen short in funding research initiatives that will eliminate the need for opioids in medical practice. That would significantly reduce the availability of these drugs. Such an effort will require funding at the federal level for new research that will lead to new drugs, behavioral interventions, alternative medical practices, devices, and health care delivery systems to replace opioids in clinical practice.

We currently spend just 4 cents per pain patient per year on research aimed at discovering and implementing new treatment strategies and delivery systems that will reduce, and ultimately eliminate, the need for prescription opioids. At the same time, pain patients account for about 15 percent of health care costs. That’s a big imbalance.

If we are to win this fight, we must resolve two interwoven health epidemics facing our nation: opioid abuse and chronic pain. We need more federal funding to develop new drugs, procedures, and health care delivery systems that will eliminate the need for opioids in clinical practice. That would eliminate a primary contributor to opioid abuse while still providing the best possible care to patients who are suffering from chronic pain.

William Maixner, DDS, directs the Center for Translational Pain Medicine and the Innovative Pain Therapies at Brier Creek and is professor of anesthesiology at Duke University.

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  • Those of us whom need the medications are being sacrificed for those abusing anything they can shove into their bodies. Its status quo: with the governments figures: 8-10% of the population abuses the substance and the 90-92% of the population is paying for their abuse. Living w/a spinal cord injury is bad enough but now having to justify being prescribed narcotics for pain is going off the chart. I have never become high or had any euphoria when taking narcotics or any other of the Rx which I have to take. I do not take Rx for the sake of being medicated. I would like, for all the band wagon cheerleaders, educate yourself instead of believing anything printed or poisted to the internet. Until that occurs the rest of the discussion is moot. I’d gladly change places w/anyone whom believes this is a “free high”. The only high item here is the conditioned ignorance of those viewing narcotics as the problem. Lets look at the prescribers, people buying narcotics outside of the pharmacy.

  • As a chronic pain sufferer I agree with the whole of the last paragraph. However… my biggest concern right now is my fellow brothers and sisters in chronic pain. So many are choosing to take their own lives, so many are now bed ridden, so many now DO NOT have the productive lives they once had. While we are being made to take drug tests, pill counts, made to feel like criminals, the law breaking heroin addicts are being catered to. There is money being pored into rehabs, clean heroin and clean needle centers popping up paid for by the government. Myself and others are outraged! Many of us are retired police officers, veterans, school teachers and the like that are being shoved under the bus!! We cannot organize because we have been taken down by having our life saving medications (not drugs) taken away!

  • Chronic Pain patients are not the problem and neither are the Opiate medications they need just to live a semi normal life.

    After nearly 10 years on the same dose of Opiate medication my Pain Management Dr. shut his doors because of the new guidelines from the CDC and the State of Pa. During those 10 years I never once misused my medication and 95% of the other patients were using their medication properly.

    People suffering from severe chronic pain and are prescribed opiates need that medication; to work, to go to school, go to church, hold a child and try to live a near normal life. Those that are truly suffering would not sell their medication or use too much – its just not worth it.

    Withholding or weaning off opiate medication for people in severe pain is not the answer and those of us that have had their medication stopped have not been given any alternative to help combat the pain. Some patients are told to have a Pain Pump surgically implanted; the Pain Pump uses smaller amounts of opiate medication that is delivered directly to the spinal chord. The Pump has many side effects and still leaves the patient dependent on the opiate medication via the pump and orally.

    I believe Opiates like Oxycodone are safer and have fewer side effects than drugs like Motrin, Tylenol and the entire family of NSAIDS. F Y I – 15,000 people will die from the use of NSAIDS this year and more next year.

    Even now the Federal Government is baffled as to why the over dose Death rate has gone up not down. No mystery here, drugs like Heroin and Synthetic Fentanyl coming in from Mexico and China are the # 1 reason for drug over dose deaths – this is according to the CDC. The CDC also announced that prescription pain medication abuse is not as bad as they first believed and has very little to do with the epidemic or rash of drug related over dose deaths. Meanwhile millions of chronic pain patients are now suffering even more because of the CDC guidelines and the DEA’s race to win a war that it helped to create. Making people suffer is not going to save lives, it will only increase the OD rate and the Suicide rate.

    With over 30 years of experience I can see how the problem started and I must say I have never seen or heard such blatant misinformation and lies coming from the media and the government that only shapes the wrong view of the facts. In the end its all about money and lots of it – Billions of dollars to be made. When a Hedge Fund is available to invest in addiction and recovery, its plain to see the real reason for the new war on pain patients.

  • I believe that medically managed opioids have a place in treating both physical and psychological pain. By criminalizing these we have created a desperate and ruthless “sub” class. We might start by decriminization and tax each substance according to its ability to cause addiction. Such taxes could defray the cost of treatment. Try looking up a society that has done just this – Portugal- in YES magazine. We must listen to patients and respect their lived experience. We must work harder at understanding the sociology of addiction, indeed we do not have even a good working explanation for addiction, although we may think we know it when we see it. I am myself a chronic pain sufferer and a close family member of a person with heroin addiction who died too young. I chose not to take any sort of pain medication, even OTC analgesics are off limits unless I am in such severe pain I cannot sleep. My observation is that people who are addicted to opioids have two monkeys on their backs: one is the need for their drug and the drive to obtain it by any means necessary, and the other is the judgemental and completely inaccurate social attitudes regarding them. No wonder recovery is so limited. I can tell you that I consider myself fortunate and that if my pain gets much worse either reliance on these drugs or suicide will be the two choices I might be faced with.

  • It seems we are sacrificing those that need help dealing w/the many faces of long standing pain issues. Like the attention seeking child, most adults just wish the child would cease to be a problem. Are we to remove the few remaining cards in our deck of to deal w/pain because of the attention seekers. The medical providers in the conservative Great Plains area of the US will not provide information to support medical cannabis or many of the other alternative avenues which show some promise in addressing the long standing problem of pain,substance abuse and other various medical problems that need fixing. Same w/our State Attorney General who spread the fear mongoring issue re: Medicinal Cannabis even though the Medicinal Cannabis vote favored a 2/3 majority to pass muster to now be accepted in ND. Instead of having the ability in 2 different legislative sessions to approve the measure, they refused to do anything other than voting it down. This past election cycle saw a great deal of press saying how poorly written the measure was and various other poor things assocoated w/medicinal cannabis. Until the talking heads decide to do something, the verbal volleyball match will continue and no one will take any positive steps towards addressing the multi-faceted issue re: substance abuse and medical ethics to cause no harm and to genuinely treat people who are in dire straights. Liability issues will continue along with few physicians willing to stand up and make a push in a healthy direction which must also include compassion. In the mean time those of us whom are very uncomfortable will continue to have any advocacy. If it were proven that a rusty nail driven through my tongue and that would make me less uncomfortable i may try it. The off-label use of many drugs, the numerous spinal cord injections w/steroids and or other cocktails created to supposedly decrease the problems has its detractions. Until the huge egos, of the medical establishment including the same with the legal interpretors of our nation, decrease and the idea of treating the patient returns nothing will be done other than continuing the same old argument. Big Pharma drives alot of vehicles in our medical and legal communities each sector has its economically viable endpoint. Until those endpoints are reached the nations providers of medical & legal services will continue to add to their bank accounts. In the mean time the junkies, dr. shoppers, black market providers of product will also continue to do the same. Those with real problems of pain & discomfort will continue to be cannon fodder for the talking heads. Time to stop chasing our tails and start taking care of those whom truely need advocates.

  • Our typical approach to everything is to create “laws” to adjust behavior. In the 1990’s surgeons as well as medical and dental professionals were accused of not caring enough for pain as part of our typical work up and so the Office of Medicare as well as the task force mandated that we all start asking about patient’s pain level. Once you focus on something the shear view will by Heisenberg naturally alter the outcome and so it did. Once every healthcare provider asked “do you have pain and if so how much” patients started to think about their pain the same pain they tolerated for the past decades or more.
    On top of that nightmare we allowed the DEA to take drugs like Vicodin and make them Schedule 2 instead of 3. That SIMPLE shift poured billions of Vicodin on the street. Instead of reducing the number of pills it INCREASED the numbers exponentially
    EVERY surgeon and Dentist and Podiatrist who would have otherwise told their patient to go home and take some NSAIDs and if you need more call us they HAD to be given a written prescription for Vicodin since we can no longer call in the script because of the Schedule shift
    Idiots in DC abound!!!!!
    Up until that point 99% of the post procedural patients did quite well on OTC stuff like Advil or Aleve now they automatically get a script for Vicodin the number one abused narcotic in the USA. Sure every photo shows Oxy and Opana but the real drug concern are the lower drugs like Vicodin because they are the hook that gets them on the drug line then once on they simply crawl up for more and stronger.
    We need to stop legislating every problem we perceive. Sure there were SOME patients who were under-treated for pain because some docs simply were afraid to step into helping chronic pain but the majority were quite fine until we tossed in the spoon and started to stir the pot. Now we are looking to un-ring the bell. Good luck with that
    Dr D
    Advisor to the US Congressional committees on healthcare process and protocol and head and neck surgical oncologist

  • Let me respond to your recent article questioning how to help the opioid pandemic Americans now suffer.

    You fail to realize the leading medical cause for the prescription of opioids is low back pain (30%) that chiropractors help best with nondrug and nonsurgical treatments.

    Please review my article, Pharmageddon @ http://chiropractorsforfairjournalism.com/Pharmageddon.html , to learn how my profession is a big answer to this pandemic of pain.

  • As a family physician and former medical director of a pain management program. I agree with you 100%. Not only do we need additional research but also guidelines, educational/training programs for health professionals and assurance that insurance will cover and provide access to these additional needed treatments. Guidelines and research are not enough if they can’t be accessed by those that need it. Our psych and physical therapy based program took care of hundreds of patients without narcotics. We had to fight for coverage for every one of those patients. When the patient would report improvement their disability payments would immediately decrease before the patient could find another job or be retrained. As you would expect the next self report showed increase in pain back to the previous level. The whole system needs to be evaluated and rationally looked at. It is like a train tracks that work but don’t connect one city or station to another. Until then health care providers and patients will seek the easiest and cheapest solution to the problem such as opioids.

  • If true engagement with the medical profession, and especially the primary care workforce is desired, the very first step is an explicit, unhedged acknowledgement by CMS, DEA and CDC that is was their policies that were originally responsible for the general acceptance of opioids to treat chronic pain (AKA the fifth vital sign) in the 1990s. Until that is done, primary care physicians are going to (rightly) assume they are going to be scapegoated with punitive and arbitrary prosecutions and their patients are going to be in unrelieved pain.

    As I write this, hospitals are still being judged on the amount of pain patients report upon discharge. CMS is “looking into the matter”.

  • It is easy to see the collusion between the FDA, DEA, big pharma, alcohol, and tobacco companies in the 1. failure to deschedule cannabis 2. do life-saving research on cannabis in pain AND addiction; 3. release non-THC industrial hemp to grow our economy here at home. They will become even more intransigent in the face of Staci Gruber’s research last month showing cognitive improvements in medical marijuana users and that: “patients reported a notable decrease in their use of conventional pharmaceutical agents from baseline, with opiate use declining more than 42%.” This is not a moonshot, this is a plant with millions of CB1 and CB2 receptors in every one of us at the ready. Let our cells vote! Whatever harm occurs will be tiny compared to the harm we’re failing to address right now. Gruber’s research: http://journal.frontiersin.org/article/10.3389/fphar.2016.00355/full

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