Curbing The Epidemic of Opioid Abuse by Rethinking Chronic Pain

Over the last few decades, medicine has witnessed a sea change in attitudes toward chronic pain, and particularly toward opioids. While these changes were intended to bring relief to many, they have also fed an epidemic of prescription opioid and heroin abuse.

Curbing abuse is a challenge spilling over into the 2016 political campaigns. Amid calls for better addiction treatment and prescription monitoring, it might be time for doctors to rethink how to treat chronic pain.

Ancient roots, modern challenges

A class of drugs that includes morphine and hydrocodone, opioids get their name from opium, Greek for “poppy juice,” the source from which they are extracted.

In fact, one of the earliest accounts of narcotic addiction is found in Homer’s Odyssey. One of the first places Odysseus and his beleaguered crew land on their voyage home from Troy is the land of the Lotus-Eaters. Some of his men eat of the Lotus, lapsing into somnolent apathy. Soon the listless addicts care for nothing but the drug and weep bitterly when Odysseus forces them back to their ships.

For decades in the U.S., physicians resisted prescribing opioids, in part for fear that patients would develop dependency and addiction. Beginning in the 1980s and 1990s, this began to change.

Based on experiences with end-of-life care, some physicians and drug companies began saying that opioids should be used more liberally to relieve chronic pain. They argued that the risks of addiction had been overstated.

Since 2001, the Joint Commission, an independent group that accredits hospitals, has required that pain be assessed and treated, leading to numerical pain rating scales and the promotion of pain as medicine’s “fifth vital sign.” Doctors and nurses now routinely ask patients to rate the severity of their pain on a scale of zero to 10.

While it is impossible to measure the burden of pain strictly in dollars, it has been estimated that the total health care cost attributable to pain ranges from US$560 billion to $635 billion annually, making it an important source of revenue for many health professionals, hospitals and drug companies.

More prescriptions for opioids have fed abuse

Today it is estimated that 100 million people in the U.S. suffer from chronic pain – more than the number with diabetes (26 million), heart disease (16 million) and cancer (12 million). Many who suffer from chronic pain will be treated with opioids.

In 2010 enough prescription painkillers were prescribed to medicate every American adult every four hours for one month. The nation is now in the midst of an epidemic of opioid abuse, and prescription medications far outrank illicit drugs as causes of drug overdose and death.

It is estimated that 5.1 million Americans abuse painkillers, and nearly two million Americans suffer from opioid addiction or dependence. Between 1999 and 2010, the number of women dying annually of opioid overdose increased five times. The number of fatalities each day from opioid overdoses exceeds that of car accidents and homicides.

Image shows pill bottles.
Doctors should examine the strengths and weaknesses of opioids. Image adapted from The Conversation.

In response, the Drug Enforcement Agency and a number of state legislatures have tightened restrictions on opioid prescribing.

For instance, patients must have a written prescription to obtain Vicodin and doctors can’t call prescriptions in. The downside, of course, is that many patients must visit their physicians more often, a challenge for those who are seriously ill.

Some patients seek multiple prescriptions for opioids so that they can turn a profit selling extra pills. The increase in prescription opioid misuse is also linked to an increase in the number of people using heroin.

A sea change in pain treatment helped create the opioid abuse epidemic, and another sea change in how doctors view chronic pain could help curb it.

Looking beyond physical pain

In a recent article in the New England Journal of Medicine, two physicians from the University of Washington, Jane Ballantyne and Mark Sullivan, argue that physicians need to reexamine the real strengths and weaknesses of opioids. While these drugs can be very effective in relieving short-term pain associated with injuries and surgery, the authors say “there is little evidence supporting their long-term benefit.”

One of the reasons opioids have become so widely used today, the authors suggest, has been the push to lower pain intensity scores, which often requires “escalating doses of opioids at the expense of worsening function and quality of life.” Merely lowering a pain score does not necessarily make the patient better off.

They point out that the experience of pain is not always equal to the amount of tissue damage. In some cases, such as childbirth or athletic competition, individuals may tolerate even excruciating degrees of pain in pursuit of an important goal. In other situations, lesser degrees of pain – particularly chronic pain – can prove unbearable, in part because it is experienced in the setting of helplessness and hopelessness.

Instead of focusing strictly on pain intensity, they say, physicians and patients should devote greater attention to suffering. For example, when patients better understand what is causing their pain, no longer perceive pain as a threat to their lives and know that they are receiving effective treatment for their underlying condition, their need for opioids can often be reduced. This means focusing more on the meaning of pain than its intensity.

This helps to explain why one group of patients, those with preexisting mental health and substance abuse problems (“dual diagnosis patients”), are particularly poorly served by physicians who base opioid doses strictly on pain intensity scores. Such patients are more likely to be treated with opioids on a long-term basis, to misuse their medications, and to experience adverse drug effects leading to emergency room visits, hospitalizations, and death – often with no improvement in their underlying condition.

The point is that pain intensity scores are an imperfect measure of what the patient is experiencing. When it comes to chronic pain, say the authors, “intensity isn’t a simple measure of something that can be easily fixed.” Instead patients and physicians need to recognize the larger psychological, social and even spiritual dimensions of suffering.

For chronic pain, Ballantyne and Sullivan argue, one of the missing links is conversation between doctor and patient, “which allows the patient to be heard and the clinician to appreciate the patient’s experiences and offer empathy, encouragement, mentorship, and hope.”

If the authors are right, in other words, patients and physicians need to strike a new and different balance between relying on the prescription pad and developing stronger relationships with patients.

One problem, of course, is that many physicians are not particularly eager to develop strong relationships with patients suffering from chronic pain, substance abuse and/or mental illness. One reason is the persistent widespread stigma associated with such conditions.

It takes a doctor with a special sense of calling to devote the time and energy necessary to connect with such patients, many of whom can prove particularly difficult to deal with.

In too many cases today, it proves easier just to numb the suffering with a prescription for an opioid.

About this addiction and pain research

Funding: The Conversation is funded by Gordon and Betty Moore Foundation, Howard Hughes Medical Institute, the Knight Foundation, Robert Wood Johnson Foundation, Alfred P Sloan Foundation, Rita Allen Foundation and the Simons Foundation. Our global publishing platform is funded by Commonwealth Bank of Australia.

Source: Richard GundermanThe Conversation
Image Source: The image adapted from The Conversation

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  1. As a EMT i see one big problem.
    Doctors are starting people out on drugs like Oxycontin without even trying pain meds like Tramadol.

    I am a chronic pain sufferer with fibromyalgia and small fiber polyneuropathy from the autoimmune disease Sarcoidosis.
    During that time i had a heart attack from the antidepressants they gave me for the chronic pain.
    later i pressured to doctors to try a off label medication gabapentin the forerunner to lyrica.
    i also got a TENS unit and used it on the worse pain areas.
    between the two i am a lot better today.

    For fibromyalgia and small fiber polyneuropathy i still have doctor tell me that the only treatment for them is antidepressants and that is all they will proscribe even though you never ask for and refused narcotics.
    they also try to tell me that my heart attack had nothing to do with the antidepressants i was given.
    For me the antidepressants did absolutely nothing for the pain.

  2. I am a %100 disabled Viet Nam veteran, shot thru the chest with sucking chest wound, shattered the #1 rib and broke two ribs in the back, one year later had to have a rt. upper lobectomy 1968, blown up by an RPG going off under my buttocks while being carried to safety, have had four back surgeries last one in February 2015 retaining rods and pins again. I receive NO pain meds at all from the Veterans Administration, they say I don’t need them, how is that for treating a disabled veteran? and yes I am in pain that keeps me up most nights and praying for peace.

    1. Bob as a Vietnam vet I have no problem getting my Oxycontin but I have heard of others who have in the same facility. My doctor just left for a tree month leave hope it will not affect on me.

  3. lovelife and the author are morons, plain and simple. I have yet to figure out why Phoenix House has created this little Dr. Mengle anti-opiod group, but given the number of banksters on Phoenix House’s board, it’s certainly a skimming operation.

    It is irrelevant how many pills are prescribed without looking at the dosage. Simply put 5/325 vicodin tabs are fairly innocuos and will more likely result in liver failure from tylenol before any other problems arise. Chronic pain sufferers such as myself generally receive 10/325’s for break out pain. However, that is due to opiod tolerance. The notion that these pills are sold and is a serious problem is spurious nonsense. Do your research. The drug cartels are the ones primarily importing these opiod meds from elsewhere. They are not coming from individuals selling a handful of 5/325’s at a time. Bush Dimbulb was getting his oxy’s from overseas, not off the street. Sorry Rush Limbaugh…People who require the stronger pills (again dosage and opiod type is important here) do not sell there scripts. Someone needing 80-100mg of Oxy/day plus norco for break through pain isn’t going to that to himself. Running out means misery.

    This is a horrible political game that is being played. If it keeps up, in 30 years, the a**hats doing this to us are going to be as revered as the “medical professionals” who tortured those unfortunate souls in the insane asylums. Here’s hoping the lovelife, the author, their loved ones, and all others connected with this horror contract Arachnoiditis.

  4. When more people die annually from prescription narcotics than from motor vehicle accidents we have a problem. And studies have shown that at 2 years after narcotics are started pain intensity is equal to that in patients who do not have narcotics in the first place, so all of you suffering should be aware that had the opioid never been started you would have equal pain, and actually be 20% more likely to be working. That said, there is no doubt that narcotics relieve acute pain, and when they aren’t used chronic pain intensifies. We truly need to find a better approach to preventing acute pain’s progression to chronic pain, and dealing with acute pain in such a way that we don’t create long term problems. And finally, we need to avoid mixing opioids with muscle relaxers, and find ways if identifying sleep apnea better to save some of the lives we are losing now.

  5. A key underlying cause of both the abuse problem and the misunderstanding of it and drug use (not abuse), in general, is a failure to clearly understand the causes of addiction. It doesn’t just happen to anyone who takes a certain drug. Addiction and physical dependency are TWO DIFFERENT things; one needs to be treated as a cause, the other as a symptom.

    Addicts are stigmatized and defensive; and there is a general desire to avoid the resulting political correctness surrounding the issue of clearly stating that they have a problem which is much deeper and wider than physical dependency on a drug. There are very real and persistent social causes of addiction which we will have to, as a society, own and correct, before the problem is curbed. As long as we refuse to do that, innocent pain patients will suffer, to the point of committing suicide due to unmanaged pain and the fear-based insensitivity and stigmatization by actually very ignorant medical professionals. Even a pain specialist’s training is very specific; they are not addiction specialists and cannot be relied upon to determine whether or not a person is really suffering pain or addiction. However, the political environment makes them very cautious towards treating with medication, in too many cases.

    Physical dependency can happen to anyone who uses enough of a drug that causes it; and, that can be very hard to overcome, because of the withdrawal symptoms. Pain medication is not the only medication that can cause almost unsurmountable withdrawal symptoms. Google “effexor withdrawal” and look in “forums” for more info.

    Preventing continued use of an unwanted drug due to inability to deal with withdrawal symptoms (which can be severe) requires medical assistance with other drugs to ease the symptoms. However, most insurance won’t pay for that kind of detox; and the detox they will pay for is strongly skewed towards treating addiction – unnecessary for a non-addict and impossible for a chronically ill person to tolerate, unnecessarily. Those who are not addicts and never have been, yet suffer intense pain must not be forced to suffer unnecessarily, due to professional ignorance and fear of repercussions from treating pain. Being forced to wean off of a drug with strong withdrawal symptoms over a year or more can add continual withdrawal symptoms to the list of symptoms which make a chronically ill person dysfunctional, unfairly.

    Comparing short term, acute pain in any way to chronic pain is totally inappropriate. There is no comparison at all between suffering the pain of childbirth for even 3 days, or the pain of recovering from a 12 hour surgery for weeks, or the pain of maintaining a high degree of physical fitness as a lifestyle choice (if you don’t understand that, train up to a 5 minute mile), and suffering chronic, mind-bending pain, indefinitely. It changes brain chemistry, brain structure, and the overall metabolism of a person, insidiously, over time, decimating who they once were – in many cases, unnecessarily. We are wasting people, by ignoring this serious problem.

    I’m fairly certain that, with both increased technology, which increases our expectation of finding solutions for things, in general, and increased life span, which will increase the incidence of otherwise functional people being disabled by chronic pain, better medications and other types of treatments will be discovered. But, for that to happen, pain has to be understood as a serious problem and addiction has to stop being blamed for the desperation of chronic pain sufferers.

    For more info, look up Dr. Forest Tennant’s “The Intractable Pain Patient’s Handbook for Survival” and read his other publications.

  6. This “research” is biased…I have Ankylosing Spondylitis (moderately severe), I am not addicted to the medications that I use. I don’t abuse the medications either. However the government will have you believe that everyone that is on these medications is a Junky and doesn’t deserve the same quality of life that everyone else has, because of it. We are the burden of society because we apply for programs that will help keep us out of debt with medical bills. That our pain is in our heads and not anywhere else. The doctors are scared and won’t adequately prescribe medication, too give us that quality of life. and this is leading to another issue in this country…Many people are turning to Heroin to get this relief they seek and are dying from it. So the government is actually creating an issue greater than that of “Over Prescribing”, The use of illicit narcotics. So the answer is, treat those with disease and those who have a car accident and are still on pain relieving meds 3 or more years later needs to be further evaluated for causation. The end to this Saga is that the DEA needs to get out of the business of medicine and let the doctors do their jobs and quit blaming those of us that are suffering from disease. because we are not over prescribed, we are diseased and no longer functioning in society and need to be, the stigma lies with those that are healthy and nowhere else !! Enough said !!

  7. The majority of patients with chronic pain who use opioids do not abuse them and do not develop addiction. There are many chronic pain patients who are intolerant of opioids or do not get sufficient relief from doses that do not cause intolerable side effects. There are some chronic pain patients who do not abuse their opioids, but do sell all or a portion of their opioid scripts in order to help support themselves and their families often because they are unable to work due to a painful condition. There are some chronic pain patients who are genetically and emotionally susceptible to addiction, who need treatment for a chronic painful condition but then develop addiction despite never having any desire or intention to use opioids improperly or recreationally. There are some people to enjoy using opioids recreationally or experimentally, like alcohol or marijuana, who never develop addiction. There are some people who started using opioids recreationally or experimentally who then develop addiction. There are some people who used opioids for acute pain, maybe only a few weeks or even days, who developed addiction. Treatment of chronic pain is a multifaceted problem involving problems with limited treatment options and access to appropriate care as well a reluctance often times on the part of patients to deal with the emotional aspects of chronic pain. Addiction is also not a problem that can be approached by a one size fits all solution. Until we can accurately screen patients for addiction and provide them proper pain management and the social support to avoid addictive behavior, we will not solve the growing problem of addiction in this country.

    While statements such as “patients and physicians need to strike a new and different balance between relying on the prescription pad and developing stronger relationships with patients”, sound good on paper, the problem is that this type of care takes a lot of physician time that insurance companies do not reimburse for adequately. I make considerably more money seeing six patients an hour for ten minutes each, than I do seeing one patient for an hour, no matter how sick or how complicated my hour long patient is. I make more money removing an ingrown toenail (about ten minutes total including diagnosis and treatment) than I do spending an hour counseling a patient on chronic pain management, risk of addiction and treatment options.

  8. It’s called CANNABIS !! look it up….25% decrease in opiate overdoses in states that legalize…

  9. Excellent point by Mr. Garneau. I suffer from chronic pain that comes in varying intensity and for varying time periods. Walking and sleeping can be extremely difficult. Opioids can enable me to function at those times, over the counter medications do nothing. Before the pain reached this level, I had a prescription for an opioid for an injury. I took one or two doses until the condition improved. The next time I took a dose was when my current condition became impossible to tolerate. By that time, the opioid had been expired for a couple of years. I have also taken an extremely regulated stimulant for several years for another chronic condition. When I don’t need to control the condition, I don’t take the medication.

    Obviously, I am not addicted to either medication. I have been using one for a number of years which should be long enough for me to become addicted if I were susceptible. I know people can be genetically predisposed to alcoholism. I wonder if one can be resistant to addiction to opioids, certain opioids, or levels, or an extended period of use? It is difficult for me to understand addiction to opioids or alcohol because I don’t experience euphoria, just a lessening of physical pain which allows me to be at least minimally physically active.

    When I read these articles, it makes me feel that maybe there is something wrong with me for using opioids to be able to move some days. Maybe I am going to become addicted? Or maybe this addiction of people with chronic pain is overblown? After all, it says in this article that 100 million suffer from chronic pain, but only 5.1% (5.1 million) abuse pain killers and only 2% (2 million) are addicted or dependent. While that is a large number of people, it is an awfully small percentage of those affected by chronic pain. Rather than making life more difficult for those suffering extreme pain, maybe they should be spending more effort identifying those predisposed to addiction, identifying the causes of chronic pain, identifying cures for chronic pain, identifying ways to prevent or treat addiction in those predisposed, etc. while allowing the majority of chronic pain suffers who benefit from opioid use to continue to receive it without feeling it is somehow shameful to use these medications

    1. The government and the people who write these articles are using People with Chronic Pain to sell their biased opinions to others and or those people who believe everything that gets published…Remember that they have to sell advertising and to do so they need an article that’ll capture the attention of the reader. The government just doesn’t give a rat’s A**, and see those of us with Chronic pain as a liability, so its an endless spiral of someone keeping a cushy job, Or something !! Nevertheless we with chronic pain are being used !

  10. I am a disabled Veteran and have been on all the various types of pain killers since a 1967 auto wreck. now at
    69 i am on Oxycontin as all the treatments to date have ruined my stomach and liver. I have tried all of the alternative’s with no success so do not give me crap about addiction until you can give me an alternative.

  11. I find it very interesting that opioid abuse is much less of a problem in states with legal medical marijuana. I believe that when patients replace opiates with cannabis, good things can happen. Of course we still have many dollars flowing from the pharmaceutical industry to elected leaders to keep this from happening on the scale it needs to.

  12. The current way we treat pain is the major problem. WHen a patient complains of pain they are immediately given opioid medication and released. In subsequent follow-up visits, patients develop a tolerance and require an increase in their medication. At some point, the patient reaches the level of perceived abuse and the doctor no longer wants to give medication. At no time has the cause of the pain been addressed and the patient is labeled an abuser and forced to seek drugs from other sources. We create and abandon the ‘junkies’ and then the matter becomes a judicial problem. What a waste of money and human resources!

  13. Another useless article! Obviously the writer does not get it. As a person suffering from chronic pain and up until 2014, taking opioids daily for 10 years, I am thoroughly pissed with the medical communities. Being nearly pain free allowed me to work and function. Now the pain is once again debilitating and the medical field has zero solutions. Nothing has improved in medicine to help with chronic pain. I played the game of the doctors and went to pain mgmt., physical therapy and therapy and found is was all of load of crap…as none of it was designed to truly ease chronic pain. But that was the very best the medical field could offer instead of pain meds. So I totally get why folks are seeking outside sources!

  14. But from a neurosciene journal no mention to treating the underlying cause of chronic pain, which is neurological. No mention of Cymbalta or Lyrica. Cymbalta has taken my neck pain from 8/10 and completely disruptive of my live to 0-2/10 and a non-issue. My Tramadol use has gone from 3-5 a day to 2-3 week. I am productive and happy and no opiods.

  15. Would it not be wonderful for these researchers to experience intractable pain such as the true sufferers? If so, the research for this article would never have been performed.

  16. my pain problem was never solved by the doctors unless they prescribed an opic, which i wouldnt take unless i was having surgery
    and only for a short time to get past the chronic pain
    but the pain i have now, was simply a problem with the bowels sitting
    on my sciatic nerve and my bowels were not functioning properly
    so, i got a probiotic from a health food store and began to take that
    within two days my bowels were functioning properly and my pain level was reduced,,,,,,there are some times when it sits,,,,,,so i increase the intake the next day and that solves the problem.

    my doctors couldnt solve this problem,,,,,,,,,even had a colonoscopy
    to see if it was in the bowels,,,,,,,the gastroentrologist,,,,,,,never suggested to me it could be the lack of good bacteria,,,but i did share
    this with him,,,,,,,,and then he told me to take a probiotic. lol

    the other pain is in my back, which i will have to have surgery to correct,,,,,,,,,and physical therapy to get all working well again.

    it took me a month and 1/2 to figure out what was causing the bowel pain,,,,,,by studying when it occurred what happened before, and after a bowel movement.

    i find most doctors,,,,,,have stopped learning,,,,,and stopped trying to
    solve problems,,,,,,,obviously they never took art. creativity is the
    hightest form of intelligence

    one doctor whom i corrected on his inability to deal with feet, got
    upset,,,,,,,,threw a teenage fit, and he was very very angry. i just
    sat there very calmly,,,,,,,not believing what i saw.

    another doctor,,,,,,,,who worked on designing a good knee,,,has stopped learning,,,,,,,,so many have plus their inability to mature.

  17. Part of the problem is the seeming avoidance of the fact that pain is mediated along two very different pathways. The primary and most essential component is the signal from the distal site that there is a problem at the site–damage, usually; deterioration, as in neuropathy; or some other cause. This signal is the cue to take action to remove the cause of the pain and encourage a method to relieve the pain. Once this instantaneous signal is transmitted, the limbic system comes into play and communicates, “Oh, that hurts! I wish it would go away,” an emotional sensation. Most people are aware that both the first and second components can be increased by focusing the attention on the pain and decreased by focusing elsewhere. For patients whose pain is such that this practice can help, their need for opiates can be greatly reduced or NSAIDs used. By using more subtle distraction, a doctor can differentiate between true pain and opiate-seeking behavior by DD patients, who have learned the appropriate number to declare in order to get the doctor to prescribe opiates (I know, I’ve watched it happen.) Of course, this approach necessitates a physician who, under ACA restrictions, can and/or will take the time and effort to perform the necessary procedures to make the discrimination.

  18. FGS: To deal with chronic pain and its treatment requires first an openness to considering all aspects of the problem. As the spouse of someone who has lived with chronic pain caused by peripheral neuropathy most of her life, and been directly involved in its treatment, I have yet to read any research that suggests the authors really understand the problem. Referring to “an epidemic of opioid abuse” rather than “an increase in opioid use” is evidence the writer just doesn’t get it. Chronic pain is like cancer: it is not a single medical problem with a single treatment. It cannot be reduced to a simple problem with simple solution. The medical community has failed in general to correctly and comprehensively articulate the problem of chronic pain, and FDA leadership has failed to do its due diligence before labeling chronic pain sufferers as drug abusers and making it so difficult for them to obtain treatment that they are driven to self-medicate with alternatives that kill them. Other than missing a few points like these, the research is just fine.

    1. curb what epidemic ? like reefer madness , it’s in their head . made up . if you go to dr for a non OTC pain relief , you should leave with the RX . it doesn’t happen that way . there’s our problem . we are not allowed to think for ourselves , and neither is DR nowadays . get the DEA and busy bodies out of medicine . there is our epidemic . today someone is going to snort a line of cocaine . someone is going to try smack . someone else is going to take 3 pain meds , cause they are an idiot ! none of that has a thing to do with our DR appointment . try this . worry about government over reach , along with your ins provider . your employer is not in the field of law enforcement . Nazi’s weeding out the Jews as they line us up is what looks like . if anyone needs tested , it’s these 3 entities . individuals are not the problem . people wanting to interject themselves into individuals lives is a bigger threat than these 2 plants . have they ever met poison ivy ? smh i’ve never wandered into an opium patch , or weed patch , but you will want to after meeting poison ivy .

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