Not long ago, even palliative care patients struggled for pain relief, prompting the World Health Organization among many other organizations to focus on pain care access. What started in the late 1980s as an effort to encourage compassionate care for terminal conditions evolved into the largest iatrogenic epidemic in history; the US is now the largest consumer of global opiates. While less than 5% of the global population, we utilize 80% of the global opiate supply and 99% of the available hydrocodonei. In fact, hydrocodone is the most prescribed medication in America at 131 million scripts, beating out the next most prescribed medication, by over 37 million scriptsii. In spite of this dramatic reliance on opiates, quality of life or functional indicators do not reflect improvement in health. Rather, opiate initiation more often correlates with future disability and worsening conditionsiii.
Many factors have contributed to the evolution of the opiate epidemic. Most efforts to address this multifaceted epidemic are narrowly focused on issues such as abuse deterrence, compliance monitoring or egregious pill-mills. But the problem rages on and metastasizes to other concerns like the growth in heroin. Introspection into our field poses risks of triggering defensiveness and denial. Nonetheless, solutions start with accountability and it involves challenging long-believed myths about pain management.
Regulatory & patient advocacy groups
Starting in the late 1980s, wide-scale advocacy platforms focused on pain, identifying many undertreated scenarios like acute injury or palliative care. The focus of these efforts hinged on liberal access to opiates – an excellent solution for some of these problems, but short-sighted for others. Pain became a dump-bucket diagnosis which no longer differentiated situations and conditions for which opiates are not the ubiquitous solution and may even cause harm. The zeal of these efforts shifted patient focus from the nuances of coping and valuable therapeutic workup to an entitlement of a painfree existence no matter what. Pain was made into the Fifth Vital Sign and a metric for reimbursement. No other field is held to a zero-tolerance standard, nor is it fair to promote the illusion of its possibility to patients.
Sedentary lifestyles and poor nutrition have made the populace vulnerable to obesity and degenerative pathologies that culminate in pain. The mantra of opiate initiation and titration to effect fails to address the underlying etiology of pain while marginalizing the motivation for change and rehabilitation. Once a patient bypasses the acute phase of opiate exposure, the physical dependency creates an impression that the pain is worse without opiates when in fact, the pain of withdrawl exaggerates the underlying cause of pain. After the pharmacologic duration of action, opiates have a rebound effect and thus magnify the pain experience when the medication has worn off. Once re-medicated, relief from the rebound pain gives the perception that only opiates can stave off pain. Patients remain in a vicious cycle with the notion that anything less than unrestricted opiate escalation is cruel.
Payor models often have unintended consequences. In pain management, there are numerous examples that hinder effective care and promote strategies without proof of efficacy. Insurance reimbursement has long focused on compliance monitoring, radiologic diagnoses (often superseding skilled physical exam findings), urine toxicology, and invasive options including surgery and joint replacement. Low health literacy obstacles regarding pain often require more time with patients, a service that is not proportionately reimbursed. It is far easier and more lucrative to operate or write a script than to dissect the problem and educate the patient. As a result patients may opt for options that are less effective and more costly to healthcare. Services often lacking in the repertoire of payers involve psychological, lifestyle counselling, rehabilitation, or regenerative options, all tools which have very strong track records of cost-efficacy.
In the short span of 20 years, opiates have become the most prescribed medication in the country, a boon to many pharmaceutical companies. Similar to strategies used by the tobacco industry, the risks and benefits of opiates were misrepresented. As a field, we trusted without verifying and many extrapolated claims trumped solid science in pain management. The conversation was often shifted to monitoring for egregious addiction or lesser adverse effects rather than the lacking efficacy or problems of physical dependency and rebound pain. Once chronically exposed, many patients cannot return to abstinence, even upon resolution of the original complaint. Thus the decision to initiate opiates and the reasonable doses prescribed are enormous life-altering choices, often sidelined by the imperative to treat regardless of a condition’s long-term response to opiates. Nationally, lawsuits have been filed against pharmaceuticals as a result of misleading claims but as clinicians we must learn from our own mistakes to vet the knowledge we gain from our pharmaceutical counterparts.
Pill mills have long been a scapegoat for the opiate epidemic. While undoubtedly unscrupulous businessmen and clinicians profited from the epidemic, the vast majority of opiates originate from well-intentioned physicians. Physicians engaged in opiate prescribing often embrace the acute improvements they hear from patients and these gains often overshadow the diminishing efficacy over the ensuing visits. In blurring the lines between opiate prescribing and true pain management, healthcare undermines the complexity of proper diagnoses and long-term planning for chronic pain conditions. Articles and CME programs can never relay the density of subspecialty training, but until recent regulations, many physicians conveyed the notion of expertise without the proper training to back it. Granted the field is new and the need is tremendous but how many nephrologists dabble in cardiology, or psychiatrists attempt a hysterectomy? Pain is not one condition for which there is a single categorical cure in opiates. Pain is the symptom of many conditions, some of which may benefit from an opiate, but many of which magnify in the context of chronic opiates.
Managing pain sustainably is possible. A well-versed pain specialist will identify the origin of pain and help the patient understand the rehabilitative options available. If the condition cannot be restored to functional status, then the objective becomes interrupting the pain pathway prior to its perception in the brain. For this there are many novel options. Furthermore, non-surgical regenerative techniques which leverage mesenchymal stem cells and growth factors are rapidly evolving to offer more options than previously available for many painful conditions. The future of pain management offers a vast array of innovative options, but healthcare must embrace a paradigm shift from symptom management with opiates to disease management by specialists who understand the many nuances of pain.
By Danesh Mazloomdoost, MD