Faculty Perspectives in Chronic Pain, Part 1 of 5
Reducing the Negative Effects of Opioids While Adequately Managing Pain
Practitioners, healthcare providers, governing bodies, and patients all agree that there are significant gaps in the adequate management of pain in our current healthcare system. In addition, there are great concerns among practitioners regarding the social effects of ramping up opioid use for the management of chronic pain. These concerns are heightened by the results of the past 15 years’ strategy for pain management.
The statistical analysis of these data underlines that since the liberalization of laws governing the use of opioids in the 1990s and the Joint Commission on Accreditation of Healthcare Organizations standards for noncancer pain management that were implemented in 2000, the use of opioids has dramatically increased.1 Despite this increase in the use of therapeutic opioids nearly 15 to 20 years later, the scientific evidence for the effectiveness of opioids in chronic noncancer pain remains unclear. Furthermore, concerns continue to surround not only the efficacy of opioids, but also opioid-related physiologic effects, such as hyperalgesia, hypogonadism, and sexual dysfunction. Coupling these significant side effects with the potential for misuse and abuse, as well as a significant increase in opioid-related deaths, the healthcare system and providers find themselves inadequately equipped to deal with the consequences of widespread and chronic opioid use.
Alarming statistics on opioid use in the United States compared with the rest of the world highlight the fact that, even though Americans constitute 4.6% of the world’s population, they have been consuming 80% of the global opioid supply as well as two-thirds of the world’s illegal drugs.1 According to sales data, frequently used opioid medications have more than doubled from 50.7 million grams in 1997 to 126.5 million grams in 2007.1 This is occurring while the US Drug Enforcement Administration and police departments in every state regularly report seizure of popular opioids from high school parties and college campuses.
In light of the very significant adverse effects of opioid use, the question remains: How do we manage chronic pain? The quest for the so-called “nonaddicting opioid” has all but been abandoned by the pharmaceutical industry. Use of alternative methods for pain management, such as nerve blockage, psychological therapies, and diet and lifestyle changes, have shown some success but in very limited and specific settings. Furthermore, alternative methods for pain management are not mainstream, and they often require resources that can be cost prohibitive for healthcare systems and for individuals.
Despite the significant adverse effects of opioid use on personal and social levels, opioids remain the most available and cost-effective way to manage chronic pain. In my opinion, to successfully manage pain and prevent the misuse and abuse of opioids, healthcare systems need to implement best practices for pain management coupled with stringent and regular blood tests to measure and verify opioid use. In addition, healthcare systems need to focus on diet and lifestyle changes, psychological group counseling, and regular follow-ups.
One of the flaws of our current healthcare system is that patients often fall into the proverbial cracks and become forgotten. For example, patients often remain on waiting lists for years before undergoing surgery for lower back, knee, neck, or other mild-to-moderate pain.2 For most of these patients, this is the starting point of opioid use. Based on my observation, unfortunately, a fair percentage of these patients continue to use opioids years after the underlying problem is treated and resolved. In addition, routine yet increasing frequency and number of prescription fills can continue for years before these patients are flagged by the systems or their providers to be evaluated or referred to pain management; by that point, they are already in trouble and often suffer from a multitude of symptoms as a result of ongoing opioid use.
In my opinion, neglecting the low-to-mid users of opioids is the root cause of our current opioid abuse epidemic because most of these patients become high opioid users within 3 to 5 years; by that point, significant effort is required to manage their addiction. On the other hand, these low-to-mid opioid users also have the highest chance of successfully discontinuing opioids and going back to their normal lives, if managed, flagged, and treated properly to address the underlying cause of their pain. Finally, maximizing supervision of low-to-mid opioid users early on in their pain treatment can provide the biggest opportunity to narrow the gap between the legitimate use of opioids for pain management and the abuse or misuse of these agents.
- Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician. 2010;13:401-435.
- Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011. http://books.nap.edu/openbook.php?record_id=13172&page=17. Accessed November 10, 2012.
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