Opioids Don’t Always Make Chronic Pain Better (and They May Make It Worse): An opioid-free approach to treating chronic pain
Published on June 15, 2012 by Mel Pohl, M.D. in A Day Without Pain blog on Psychology Today
The efficacy of opioids as a treatment for chronic pain not related to cancer was the focus of a recent two-day public meeting held by the Food and Drug Administration (FDA). Though more study is needed, pain doctors and researchers were in agreement that there is a lack of scientific evidence to support that opioids are effective as a long-term treatment for persistent pain. Some doctors believe, as I do, that long-term opioids are not helping most people. Yet today opioids and combination drugs are the most-prescribed medications available and promoted for the treatment of chronic pain.
Opioids, drugs like oxycodone (OxyContin, Percocet, Percodan) and hydrocodone (Lortab, Norco, Vicodin) have extremely effective analgesic or pain-relieving properties. These medications were once used primarily to treat cancer pain or acute (short-term) pain, such as from injury or surgery. Then in 1995, pain advocacy groups—organizations that receive funding from drug companies—began to issue statements and policies endorsing the use of opioids to treat chronic pain, and downplaying risks such as side effects, dependence, risk of overdose, and addiction. Pharmaceutical companies have since spent (and made) billions marketing and promoting these drugs to healthcare providers and directly to consumers. These efforts to expand the market for opioid painkillers have been very successful in terms of financial gain for drug companies, but not for quality of care or improvement in patients’ lives.
Pain—the Fifth Vital Sign
In 1999, the Veteran’s Administration launched an initiative that encouraged healthcare providers to document pain in all patient evaluations using a 0 to 10 rating scale, and then to treat the reported pain with drugs. The Joint Commission (formerly JCAHO), an accrediting body for hospitals and treatment centers soon endorsed this method, declaring pain “The Fifth Vital Sign,” along with temperature, pulse, respiration, and blood pressure, and mandating that hospitals provide pain assessment and “proper” treatment for all patients.
To assess chronic pain, clinicians typically rely on patient self-reports to determine pain levels. However, chronic pain patients often perceive emotional pain as physical pain. Additionally, relying on self-report to determine appropriate use of medications is problematic, particularly in clients who have crossed the line into addictive drug taking and can no longer accurately assess their level of pain (“on a scale of 1 to 10, my pain level is 20”). These self-reports may not accurately reflect their pain levels, but may be an attempt to get more medication and stronger drugs. The proper response to these reports of increasing pain may not be more opioids.
We Are in the Midst of an Opioid Epidemic
Between 1991 and 2010, prescriptions for opioid analgesics rose to 209 million—from 75 million. The rationale has been that we don’t want people to suffer; we don’t want to deprive people of pain treatment, so we give them lots of meds. But this has catastrophically backfired. Opioids are not a panacea and are not appropriate for everyone. The use of these painkillers can be very dangerous. As the number of opioid prescriptions increase, complications, including death, are rising.
According to the CDC, in 2010, enough opioids were prescribed to treat every person in the US with Vicodin 5mg every four hours for a month.
In 2009, more people in the US died from prescription medication overdoses than from motor vehicle accidents.
There are more deaths from prescription drug overdose than from cocaine and heroin combined.
Other significant health risks of chronic use of opioids include hyperalgesia (an increased experience of pain), side effects (cognitive impairment, constipation, sleep disturbance, hormone and immune system abnormalities), tolerance, physical dependence, and addiction.
We are overprescribing opioids. Clearly they are not helping everyone who takes them,, and are making many people’s lives worse. Studies are lacking that discern the true outcome of long-term opioid treatment for chronic pain and the incidence of the potential problems.
I believe that the primary cause of the prescription drug epidemic is an intense desire to avoid or relieve feelings—physical sensations and emotional experiences. It’s the result of the futile search for pain relief and numbness in a world that’s filled with pain and suffering. It is unlikely that we will find the right drug or drugs to treat our pain and suffering effectively. There are many alternative treatments that may be effective for chronic pain sufferers, and I will review some of these in future posts.
Some speakers at the FDA meeting expressed concerns that limiting access to opioids could affect those who really need them, unfairly depriving them of pain treatment. This is a real dilemma. But with long-term use of opioids, the potential harm is likely to outweigh the benefits for most. Because of tolerance and physical dependence, requiring ever-increasing doses, in addition to side effects, the long-term picture is often bleak.
The DEA and FDA have created a panel of experts to develop Risk Evaluation and Mitigation Strategies (REMS) to minimize the risk of inappropriate prescribing and bad outcomes. Improving the way painkillers are prescribed will reduce the number of people who misuse, abuse, or overdose from these powerful drugs, while making sure patients have access to safe, effective treatment.
This article first appeared on the Psychology Today website.