The Evolving Pain and Opioid Conundrum: Addressing The Opioid Problem in the US
Drew W. Edwards, EdD, MS & Adrian Blotner, MD
Conundrum; Noun: A confusing and difficult problem or question.
‘one of the most difficult conundrums for the experts’
The National Institute of Health reports that nearly one-third of adults in the U.S. have chronic pain. At the same time prescriptions for chronic non-cancer pain rose by 300% over the past two decades.
At first, the potential for addiction to a long-term prescription of opiate “narcotic pain medication” for chronic pain was greatly underestimated by the medical community, associated with the education provided by pharmaceutical companies marketing the newly available “long-acting” opiate “narcotic pain medication.” Significant numbers of patients had significant adverse effects to their prescribed opiates, including overuse, addiction, and some even died due to overdose.
Increasing popularity and lack of oversight on prescribed long-term, relatively high-dose narcotic pain medications led to a sudden proliferation of a new type of medical clinic, known as the “Pill Mill.” “Pill mills” is the term that has been used to describe these “Pain Clinics” where high dosages of long-term opiate “narcotic pain medications” were routinely prescribed, in the absence of other treatments (such as physical therapy, non-addictive meds & behavioral treatments), often with minimal evidence for cause of the underlying pain condition, and minimal monitoring for opiate medication adverse effects, including the risk of addiction. In these “Pill Mills,” it became easier for those with addiction problems to inappropriately seek & receive prescribed high-dose long-term opiate “narcotic pain medication.”
During recent years, the availability of prescribed “narcotic pain medications” for chronic non-cancer pain has decreased during recent years as federal, local and state governments have “cracked down” on the opioid “Pill Mills.” There has also been pressure by federal, state, and local governments for all healthcare prescribers (including those NOT associated with “Pill Mills”) to reduce the number & quantity of prescriptions they write for opiate “narcotic pain medications”
One major “side effect” of the pressure by federal, state, and local governments for healthcare prescribers to reduce opiate prescriptions has been an increasingly severe problem in recent years – the availability of illegally manufactured, illegal, non-prescribed opiates that are inexpensive and easily available “on the street.” Evidence for this problem includes survey data that show a disproportionate rise in mortality attributable to fentanyl/analog tablets (72.2%) and heroin (20.6%) when compared with prescription opioids at a mere 2.6%. (NIDA 2016). [Non-prescribed fentanyl tablets are illegally produced and only available “on the street” – not an FDA approved medication and have never been available to be prescribed by physicians).
Law enforcement sources indicate that drastically increased use of lower cost and easier availability of illegal opiates such as heroin and illegally manufactured fentanyl pills have associated with a drastic rise in the price of non-prescribed “pain pills” purchased “on the street.” Illegally manufactured, readily inexpensive, and easily obtained heroin and counterfeit look-alike-prescription opioids are now the major source of the current “opiate epidemic” in the US.
But the “Opiate Epidemic” crisis should not be confused with the daily challenges faced by 100 million Americans suffering from chronic or intractable pain.
Another major opioid problem or “side effect” of the pressure by federal, state, and local governments for healthcare prescribers to reduce opiate prescriptions has been an increasing difficulty for those with severe chronic non-cancer pain conditions to have access to appropriately prescribed opiate “narcotic pain medications,” resulting in large numbers of those who suffer from chronic non-cancer pain to have persistent severe suffering and impairments that are treatable. These individuals have objectively identifiable “pain generators” as a cause for “real pain” that is severe enough to require prescribed opiate “narcotic pain medications” for relief from their suffering and improvements in their functioning.
What To Do About The Opioid Problem?
For those suffering from chronic or intractable pain, the vast majority of healthcare providers continue to endeavor to provide safe and effective substance use disorder treatment. Most are appropriately wary of the opioid problem and potential for overuse of opiates and/or invasive procedures for treatment of chronic non-cancer pain.
With the help of new Centers for Disease Control (CDC) Guidelines (April 2016), the emphasis of recommendations for the treatment of chronic non-cancer pain has shifted back emphasizing to physical therapy, non-narcotic medications, stress management/lifestyle adjustment, and invasive procedures for the reduction of pain. Procedures for the reduction of chronic pain include epidural steroid injections (ESI’s) and spinal cord stimulators (SCS’s). Surgical procedures to stabilize structures of the neck and back remain an option that may be effective for those with identifiable structural causes of their chronic pain, such as spinal stenosis, where identifiable structures of the spinal column are impacting the spinal cord or related nerves that transmit pain. As always, surgical procedures should be carefully considered for the potential of adverse effects, including worsening of pain in some cases.
There do remain a large number of individuals who suffer from “real” chronic pain with identifiable causes who do not have addiction problems and who have only limited benefits from non-opiate treatments noted above. For these individuals, carefully selected, dosed, and monitored long-term treatment with narcotic pain medication for chronic non-cancer pain may result in significant improvement in functioning without clinically significant adverse effects, but one risk of prescribed long- term treatment with narcotic pain medication is an addiction.
For those who continue to suffer from chronic non-cancer pain and are disappointed with the limited benefits they’ve received from treatments as noted above, there continue to be some practitioners who specialize in “Pain Management,” many of whom hold credentials in Addiction Medicine & Pain Management. The majority of these specialists today perform thorough assessments regarding causes of chronic pain, attempt to screen for those who may have addiction problems, and offer a variety of medication and invasive treatments to offer (procedures) for those with persistent, treatment-resistant chronic pain. Unfortunately for those who are appropriately prescribed long-term narcotic pain medication and do NOT have signs of addiction, many are now being unfairly labeled “drug addicts” for cooperating with safe and appropriate treatment for their chronic pain.
It Is Possible To Have Both Real Chronic Pain And Addiction
Regarding long-term narcotic pain (opiate) medication treatment for chronic pain, “Aberrant Behaviors” are those that indicate increased risk for addiction. They include:
- Functioning is getting worse in major life areas such as work, school, or home
- Continued use or overuse despite persistent social or interpersonal problems
- Important life activities are decreased or given up because of the substance use
- Involvement in a motor vehicle accident(s)
- Unauthorized dosage escalations (especially if this occurs repeatedly)
- Unauthorized attempt to obtain pain medication from more than one prescriber
- Aggressive complaining about the need for pain medication higher doses
- Use of pain medication to treat non-pain symptoms (mood, anxiety, sleep)
- Borrowing, buying or stealing pain medication from “friends” or family
- Recurrent complaints of lost or stolen pain medication
- Concurrent use of illegal drugs
At Lakeview Health, our solution to the pain and opioid problem is our Pain Recovery Program which emphasizes treatment with non-addictive medications, physical therapy that actually reduces pain and “does no harm,” and stress management/lifestyle adjustment to reduce the amplifying effects of stress and lifestyle on chronic pain. As all medications and other addictive substances are gradually reduced, our commitment is to minimize the discomfort of this transition, and to maximize relief of underlying chronic pain, mood, anxiety, and/or sleep disorder symptoms as they emerge. The goals of our treatment program include gradually improving an individual’s ability to manage their suffering & discomfort with non-medication techniques. These techniques become more effective when added to the benefits of appropriate non-habit-forming medications that are “doing no harm.”
If you or a loved one suffer from substance use disorder or addiction, with or without a chronic pain condition, please do not hesitate to contact us to speak with a professional who understands the difficulties that these conditions cause for individuals and their families, and about what steps you and your loved ones can take to move forward.