President Trump officially made opioid addiction a public health emergency last week. While some of the solutions he outlined will be helpful, his focus on restricting access to legitimately and appropriately prescribed opioids is the wrong approach.
Many people call the current crisis an opioid epidemic. But what we really have is a chronic pain mismanagement problem. I treat patients with chronic pain and opioid addictions. To me, such addictions are the consequence of our failure to provide appropriate treatments for chronic pain. The flood of prescription opioids that has fueled this crisis is in large part the result of prescribing these powerful drugs as a quick solution to mask pain rather than treat its underlying causes.
The National Academy of Medicine estimated that pain affects more than 100 million Americans and costs us $600 billion a year. These are more than just numbers that add up to a crisis. These are suffering people and families in need of compassionate, whole-person, and effective approaches to controlling their pain.
Sadly, we don’t have such a system in place right now. Instead, our solution for treating chronic pain relies primarily on addictive medicines designed to suppress symptoms, with little regard for the mental and emotional impacts of pain.
At age 80, Diane (not her real name) came to see me because her primary care doctor began limiting her access to the opioid painkillers she has been carefully taking for years but offered her no other means to control her pain. That’s wrong. She told me was having difficulty managing her pain and was desperately looking for other solutions. Could I help her?
I understood why she was looking for a new way to manage her pain. Her treatment hadn’t been patient-centered, meaning focused on her needs and her perspective, nor was it integrated with non-pharmacologic treatments focused on helping control her pain and improve her function. Instead, it was all about controlling her drug use.
That’s what worries me about the president’s approach to the opioid crisis. It isn’t focused on curing addiction or adequately treating the pain that fuels it. We’re just making it harder for people to get drugs — which adds to the burden of human suffering and desperation — and calling it a solution.
An integrative approach is the appropriate combination of drugs with complementary and non-pharmacologic methods such as acupuncture, mind-body methods, yoga, massage, and manipulation that can ease patients’ suffering without making them addicted to opioids. Such an approach can also help patients who have already become dependent on opioids.
The evidence is in for many of these treatments. National organizations like the Veterans Health Administration and the American College of Physicians, as well as the Centers for Disease Control and Prevention and Food and Drug Administration, have made recommendations to use non-pharmacologic and integrative approaches for pain first and continuously.
The just-released Federal Pain Research Strategy, issued by a committee within the National Institutes of Health, recognizes the value of integrative care for pain management, recommending increased attention and research into complementary medicine and self-management to treat pain. The National Pain Strategy serves as a blueprint for managing pain in America. It contains recommendations that move us toward more team-based care, better-educated physicians and the inclusion of evidence-based non-pharmacologic treatments. This document gives us the answers, but its implementation is largely stalled.
The frustrating bottom line is that we know what to do, but doctors aren’t being trained in this approach nor are there funds to do that.
In my practice, I use a tool called the Healing-Oriented Practices and Environments (HOPE) note. It involves a series of questions aimed at evaluating not just a patient’s chronic pain but his or her own ability to manage pain and general health. It complements the SOAP note (subjective, objective, assessment, and plan) that doctors usually use to document a patient visit. Then I work with the patient to develop a meaningful plan that matches his or her strengths and priorities with activities to reduce pain and improve function and wellbeing in everyday life. We set and track goals, then support the patient along his or her healing paths.
Here’s the plan that Diane and I came up with: As we gradually reduced her opioid dosage, she began regularly getting acupuncture. She sees a behavioral therapist. She is taking yoga classes. She is learning relaxation and stress management techniques with help from an alpha stimulation device. All these measures will help her body learn new ways to combat pain — and get off opioids. By infusing Diane’s pain management with effective, integrative approaches, she is now on her way to managing her pain without opioids.
Another patient of mine had been experiencing chronic pain for two years before being diagnosed with fibromyalgia. She was not taking opioids when she came to see me, but she needed help. I asked her about her childhood, because people with chronic pain often have a history of childhood trauma.
She burst into tears. No doctor, she said, had asked her about her childhood before — and it was traumatic. I explained to her that she stood a better chance of getting her pain under control if we could find a safe way for her to address the emotional scars left by her early childhood traumas. In the meantime, she is doing tai chi and stress reduction therapy to help manage her pain.
Turning off the tap on prescription painkillers will not solve the opioid crisis. More likely, it will just drive it underground — or even increase the use of illegal drugs like heroin. We need to do more, including making integrative health the standard of care. Tackling the opioid crisis will be that much easier if we reduce the legitimate demand for prescription opioids through better pain care, not just fewer pills.
That means having conversations with our patients, finding out about their everyday lives, and working with them on plans that make the best use of their body’s ability to heal with the most effective non-pharmacologic treatments available. For patients who are already dependent on opioids, we must help them reduce their use of these drugs while providing them with evidence-based alternatives and support.
Whatever you call today’s opioid addiction problem — a crisis, an emergency, or an epidemic — it reflects a sea of pain and suffering that urgently needs new and better solutions. We must stop relying solely on drugs and treat our patients as whole people as we seek to help them control their pain and improve their overall health and well-being.
When Congress and the Trump administration make choices about where to send funds to deal with the opioid crisis, they should steer some of this funding toward connecting patients with existing integrative care where it is available and expanding it everywhere else. This will help people in pain, people struggling with addiction, and all Americans who face chronic conditions who need more than a pill.
Wayne Jonas, M.D., is executive director of the Samueli Integrative Health Programs, former director of the National Institutes of Health Office of Alternative Medicine, and a retired lieutenant colonel in the Medical Corps of the United States Army.