The Perils of Pain Meds Revisited

Opioids should be avoided in the large group of patients with chronic pain due to central sensitization, such as fibromyalgia and chronic non-structural low back pain, in which co-morbid mental health disorders are common (e.g., depression and PTSD) and often lead to even higher risks of abuse.

This correlates with the 2016 CDC Guideline developed after the above NIH study, which significantly limits opioid prescribing for chronic noncancer pain while emphasizing instead non-opioid, multidisciplinary management strategies utilizing a biopsychosocial approach.¹³ These techniques foster active patient-centered strategies, in contrast to that of opioid analgesics, which often lead to passive treatment attitudes, illness beliefs and behaviors, especially in the presence of poor coping skills and persistent psychosocial stress. Since the introduction of the CDC Guideline, there has been an additional reduction in opioid prescribing.¹⁴

The above multidisciplinary biopsychosocial approaches are not new and were previously discussed in the rheumatological literature before the opioid revolution became well established;^15-18 this includes the self-management and self-efficacy principles first promoted by Kate Lorig, DrPH, Stanford University, Palo Alto, Calif., and the Arthritis Foundation in the 1980s.¹⁹

Unfortunately, the proper evaluation and treatment of patients with chronic noncancer pain by the general medical community have been impeded by the rush to opioids movement and are seriously deficient today. This mandates a much greater evidence-based educational effort independent of the opioid pharmaceutical industry.

The above recommendations refer mainly to preventive strategies in opioid-naive patients with chronic noncancer pain, with the imperative of avoiding the development of opioid addiction and overdose death, which increase with dosage and in combination with other centrally depressing drugs and substances, such as benzodiazepines and alcohol.^8,20 This polypharmacy is particularly common in patients with significant mental health co-morbidities. A major educational goal should be centered on preventing the iatrogenic creation of the potentially fatal disease of opioid addiction, which is driving the opioid overdose death rate.⁵

Prevention

Opioid addiction is one of the most difficult diseases in medicine to diagnose and treat and frequently overlaps with chronic pain. We now have a large population of patients with chronic noncancer pain who are dependent on opioids, many of whom have an opioid use disorder, which is often not recognized as such, while there is a great unmet need for addiction treatment services, including medication-assisted treatment, especially with buprenorphine.^21-23

Contributing factors to this precarious situation, which is adversely affecting the practice of medicine today, include:

1. The nature of addiction itself, which is characterized by denial, deceptive behavior, fear of withdrawal symptoms (e.g., pain), frequent relapses, limited periods of medical observation and the desire of many providers to avoid direct patient confrontation;
2. The ease of maintaining patients on opioids compared with opioid-tapering regimens or referrals for addiction treatment (note that many physicians are reluctant to diagnose addiction or are unaware of its possibility in patients with chronic pain); and
3. The business model of opioid prescribing, in which patient satisfaction survey responses to pain control questions can influence physician employment status.²⁴

There is a pressing need to improve our methods of identifying patients with opioid use disorder and referring them for addiction treatment in the context of limited resources and without risk to physician job security. For other patients, a strategy of gradually tapering opioid dosages with the goal of lower doses or eventual discontinuation while preventing adverse withdrawal reactions may be best. For others, safely maintaining opioid therapy with close surveillance and monitoring to reduce the risks of addiction and overdose death may be appropriate. Unfortunately, at the present time, we are a long way from accomplishing this.

Broad Strokes

The necessary public health solutions must be comprehensive, with the full acknowledgment, cooperation and coordination of the entire healthcare system, working in concert with government at all levels, as well as with the criminal justice, educational and social systems, and with special emphasis on education and the prevention of opioid addiction by developing/implementing pain management core competency education for practicing clinicians.²⁵