It seemed like a good idea — a Decade of Pain Control and Research, called by the US Congress in 2000 to address inadequate pain management. But what followed was disastrous. Opioid prescriptions increased 300 percent between 2000 and 2010, accompanied by rises in opioid addiction and deaths among patients and others who got hold of the medicines. Demand for opioids also fueled illicit sales of heroin and the powerful opioid fentanyl; heroin and fentanyl-related drugs now account for more deaths than do typically prescribed opioids.
Chronic pain is both difficult to control and incredibly common, afflicting more than 30 percent of American adults and about 50 percent of the elderly. Because high doses and long-term use of opioids raise the risk of addiction, doctors worry more about opioid prescriptions for chronic-pain patients than those who need the medicines for just a few days. Indeed, an estimated 8 to 12 percent of people who take opioids for chronic pain develop an opioid-use disorder — recurrent use despite negative consequences. Addiction is the most severe form.
Knowable Magazine spoke with Nora Volkow, director of the National Institute on Drug Abuse, who recently coauthored an article on the use and misuse of opioids in chronic pain situations for the Annual Review of Medicine. She shared her thoughts on how best to treat enduring pain in the face of the opioid crisis. The conversation has been edited for length and clarity.
Is it true that until recently doctors thought that patients in pain would not become addicted?
That’s the way many of us were trained: If you had a patient who had pain, you shouldn’t be concerned about them getting addicted to their opioid medication. This belief was utterly unfounded.
Does pain actually increase the risk for addiction?
There is relatively limited research. Addiction is triggered by “conditioning,” the association between consumption of a drug and a pleasurable response. But a drug also can be incredibly rewarding if you have horrible pain and then you take something and it’s gone. It depends on the context, but certainly in some of the animal experiments, high doses of opioids are more rewarding if you have pain than if you don’t.
Guidelines from the Centers for Disease Control and Prevention for treating chronic pain favor nonopioid therapies over opioids. Are nonopioid drugs as effective as opioids?
There are other medications for some chronic-pain conditions: some anti-epileptics, antidepressants, nonsteroidal anti-inflammatories. There is no evidence that opioids work better than other drugs to improve function in people with chronic pain. Having said that, we have to recognize that for some patients who don't respond to anything else and are in severe, severe pain, the intermittent use of opioids can help.
It should not be a first line of treatment, as the CDC very explicitly states; it should be part of a comprehensive plan for management of chronic pain. Unfortunately, these more comprehensive plans are not always reimbursed and, even if they were, there is not the expertise to actually provide them.
By “comprehensive,” do you mean behavioral therapy and things like that?
Behavioral therapy. Physical therapy. Complementary therapeutics, like meditation. There are also interventions to improve sleep behavior patterns that have been shown to decrease pain.
Do you also need to change patients’ expectations for pain control?
These interventions are going to be much more time-consuming than just giving an opioid pill, and also are not going to lead to the immediate relief that you get with an opioid. And so you also have to change expectations. There is increasing recognition that we should make patients expect that the intervention will help them lead a more normal life and resume their everyday activities, even though they may have to learn to live with some level of discomfort — as opposed to having them expect that any sensation of pain is going to go away.
Let’s go back to the expertise issue. Isn’t that a big problem?
We need change in the structure of the medical system. The NIH is interested in the development of new models of how to take care of patients with chronic pain conditions, such that physicians may oversee a team of experts that deploy, for example, behavioral, meditation and complementary-medicine interventions. Nurses and physician assistants would be engaged in the process.
Is the idea, partly, that patients would be trained to manage pain on their own?
That’s the process — to empower patients to modulate their own perception of pain, to gain more control over their emotional reaction to pain. So while you may be perceiving pain, you do not need to get as distressed by that sensation, and that can make it much more manageable.
Are there any good data on the effectiveness of these nondrug therapies?
Randomized clinical trials that have shown that hypnosis — I’m just giving you an example — can significantly improve the outcomes of patients suffering from pain. Acupuncture and meditation, also. The issue is, how large have these clinical trials been and for what pain conditions? It is clear that chronic pain comes in multiple flavors and that we need to develop targeted interventions for specific pain conditions, as opposed to what we've done in the past — just lump everything together into “chronic pain.”
Your review explicitly focuses on chronic pain that is not caused by cancer. Why?
The issue relates more to having a terminal condition versus one that is not. When someone has terminal cancer pain, or is in a terminal condition of another type, there is not so much concern that you are going to be living for many years and thus struggling with addiction.
Looking back at the review, we should have made clear that when there is a chronic issue with pain for cancer in a non-terminal situation, then one should use the same considerations that apply to any other chronic condition with pain.
Patients who have been on opioids for years for pain are being abandoned by doctors spooked by the opioid crisis. Is that a reasonable response?
I have seen it, too. It is very stressful for patients, and it is putting some at very high risk for either overdosing or suicide. You can have a patient who is addicted to their opioid medication, and the physician just cuts them off without proper referral for treatment for their opioid-use disorder. As a result, they have the distress of the addiction — the intense craving, plus the severe, severe physical withdrawal, which is also very uncomfortable — and that puts them at risk of going into the black market to get heroin and/or synthetic opioids. Now that a very high percentage of those drugs are laced with fentanyl, this puts the patients at high risk of overdose.
Then there are patients who have very severe chronic pain that doesn't respond to anything else, who have some relief from their opioids, getting horrifically distressed at the fear of having the pain return full-blown. You have patients who will kill themselves rather than see no hope for the management of their chronic pain.
We want to protect people from getting exposed to opioids when they don't need them, so we come up with measures that then, unfortunately, are affecting those that need them.
Similarly, Medicare has considered refusing to pay for long-term, high-dose prescriptions for its beneficiaries, and states and private insurers have set hard limits.
These rules reflect the urgency of the situation. If we are going to limit in such a draconian fashion the delivery of opioid medications to patients with chronic pain, we need to ensure that they have the support system to manage their pain and, if they have an opioid-use disorder, proper referrals for treatment of it. Otherwise, we are going to do a lot of harm.
Are some doctors mistakenly interpreting physical dependence as addiction?
We wrote a paper for the New England Journal of Medicine to try to clarify this for physicians. If you end up in an accident and in the hospital and they give you opioids for three days continuously, you will be physically dependent on the opioids; this is very different from addiction, and emerges very rapidly.
I speak from experience. I was in a car accident and hospitalized and released with opioids. I didn’t want to take them, so I went cold turkey and had physical withdrawal. The withdrawal was very disagreeable and forced me to take one of the pills even though I didn’t want to.
Addiction, on the other hand, takes much longer to develop. Not everyone getting the drugs will become addicted. A physician seeing that a patient with pain is starting to have symptoms of withdrawal may then describe that patient as addicted when they are not; they have physical dependence. And that leads to improper management.
It sounds like many doctors need to be better educated about the best ways to manage pain care.
Probably the lowest-hanging fruit, and what we should be doing right now, is expanding aggressively the proper training of physicians and health-care providers in the recognition and management of addiction. Things as simple as recognizing the difference between physical dependence — withdrawal — versus addiction, and how you determine when you should refer someone to specialized care. Providing that basic learning and understanding is item number one.
We are hurting patients when we come up with a measure that leaves them with no alternative. But the other reality is that by overprescribing opioids, we were hurting patients — not just by increasing the likelihood that they could overdose or become addicted but because chronic opioid use actually can exacerbate pain, can produce “hyperalgesia.”
Opioids can worsen pain?
In some instances, pain medication that initially provided great relief will exacerbate sensitivity to pain, and so make it worse. When you have a patient who is already on very high doses of opioids yet those are insufficient to control the pain, you might want to consider tapering off. In some instances, the pain will actually get better.
What else would help improve care?
We need to emphasize to doctors the responsibility we have to patients with severe, chronic pain. Changing the way that we reimburse physicians would help ensure adequate care. If you have fifteen minutes to take care of a patient with a complex pain condition, there is no way that you are going to be able to properly address their needs. You should be reimbursed for outcomes and be given the opportunity to have much more time so you can understand the unique needs of that individual — which may include intermittent use of opioids as part of a comprehensive approach. But that will require much more time investment and the resources and expertise of a team to help you do it.
What is the government doing about education?
At the NIH, as part of the Pain Consortium, we have been supporting Centers of Excellence in Pain Education across the United States for the development of educational curricula for medical students, specialty physicians, nurses, pharmacists and dentists, that will be free and available for schools.
Is there anything else important to mention?
I very much want to emphasize the opportunity we have here: We have medications that can be used for the treatment of opioid-use disorder, and these medications can be very beneficial. It is important for every physician to know how to properly screen and recognize indications that patients may be early in experimenting with drugs, or misusing them, or fully addicted.
Also, we need to recognize that our beliefs about demographics — that it is the young person that is more likely to become addicted — does not necessarily fit the bill. You should monitor every single person, in a nonjudgmental way, for substance-use disorder, the way you monitor for diabetes or allergies.