Managing Chronic Pain: Opioids Are Often Not the Answer
Posted on by Dr. Francis Collins
The term “silent epidemic” sometimes gets overused in medicine. But, for prescription opioid drugs, the term fits disturbingly well. In 2012, more than 259 million prescriptions were written in the United States for Vicodin, OxyContin, and other opioid painkillers. That equals one bottle of pain pills for every U.S. adult. And here’s an even more distressing statistic: in 2011, overdoses of prescription painkillers, most unintentional, claimed the lives about 17,000 Americans—46 people a day [1].
The issue isn’t whether opioid painkillers have a role in managing chronic pain, such as that caused by cancer or severe injuries. They do. What’s been lacking is an unbiased review of the scientific literature to examine evidence on the safety of long-term prescription opioid use and the impact of such use on patients’ pain, function, and quality of life. The NIH Office of Disease Prevention (ODP) recently convened an independent panel to conduct such a review, and what it found is eye-opening. People with chronic pain have often been lumped into a single category and treated with generalized approaches, even though very little scientific evidence exists to support this practice.
Based on its review of the literature and scientific research presented at the workshop, the seven-member panel concluded that chronic pain spans a multitude of conditions, presents in different ways, and requires an individualized, evidence-based approach to manage. The workshop was convened by ODP, the NIH Pain Consortium, the National Institute on Drug Abuse (NIDA), and the National Institute of Neurological Disorders and Stroke (NINDS).
Such individualization won’t be easy to achieve. Data were presented showing that people with peripheral pain, caused by tissue damage or inflammation, may respond better to opioids than other types of painkillers. This group includes people with cancer pain, rheumatoid arthritis, and severe pain due to injury. On the other hand, people with central pain syndromes, characterized by disturbances in the processing of pain by the brain and spinal cord, may respond better to antidepressants and anticonvulsants than to opioids. Such syndromes include fibromyalgia, irritable bowel syndrome, temporomandibular joint disorder, and tension headache. To add to the complexity, some workshop attendees cautioned against making sweeping statements about which types of patients are—and are not—most likely to benefit from prescription opioids.
The panel’s report, a summary of which was just published in the Annals of Internal Medicine [2], contains many other valuable insights. For example, I was deeply troubled by how little scientific evidence exists to support the safety and efficacy of long-term opioid use; most clinical studies on opioids and chronic pain have lasted 6 weeks or less. That is a serious knowledge gap, especially in light of the fact that up to 8 million Americans use opioids for long-term pain management—and the known side effects of short-term opioid use include nausea, mental clouding, and respiratory depression, along with overdose. Until more scientific evidence is generated on the effects of long-term opioid use, the panel suggests that people seeking help for chronic pain be initially encouraged to try non-drug approaches, such as physical or behavioral therapy. If such approaches fail to ease the pain, potentially riskier drug options, including non-opioid and opioid medications, could then be explored—but with great care.
As is increasingly the case for all areas of medicine, the panel concluded that the best pain management strategy is one tailored to identify and meet a patient’s individual needs. Taking this point a step further, the panel recommended that initial patient evaluations go beyond a standardized pain assessment (On a scale of 1 to 10, what is your pain level?) to consider more fully the whole patient—from quality of life and psychological wellbeing to the presence of other pain-causing conditions and sensitivity to pain.
A lot of this may be easier said than done. The expert panel acknowledged that, in the real world, many healthcare providers currently do not have the time or the tools to conduct such detailed evaluations, and some health insurers do not cover non-drug interventions or non-opioid drugs as first-line treatments for chronic pain. Furthermore, once a healthcare provider has prescribed an opioid drug to a patient with chronic pain, there are insufficient data on drug characteristics, dosing strategies, or tapering to guide clinical care effectively.
Clearly, NIH can’t address all of these challenges alone. However, we are taking very seriously the panel’s call for more research to generate the evidence-based, multidisciplinary approaches needed to bring safe and effective relief to the millions of Americans living with chronic pain.
The NIH is also doing everything it can to use the power of science to reduce the very serious public health problem of the abuse of opioid painkillers and other prescription drugs. In fact, on April 7, I’m scheduled to be among the NIH scientists presenting at The National Rx Drug Abuse Summit, which is a collaboration of professionals from government, business, academia, clinicians, treatment providers, counselors, educators, and advocates who are deeply concerned about prescription drug abuse.
References:
[1] Vital Signs: Opioid Painkiller Prescribing, Centers for Disease Control and Prevention, July 2014.
[2] National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain. Reuben DB, Alvanzo AAH, Ashikaga T, Bogat A, Callahan CM, Ruffing V, and Steffens DC. Annals of Internal Medicine. 2015 January 13.
Links:
Pathways to Prevention: The Role of Opiods in the Treatment of Chronic Pain (ODP/NIH)
National Pain Strategy, Interagency Pain Research Coordinating Committee, U.S. Department of Health and Human Services
Prescription Drug Abuse (NIDA/NIH)
National Drug Facts Week (NIDA/NIH)
NIH support: NIH Office of Disease Prevention; National Institute on Drug Abuse; National Institute of Neurological Disorders and Stroke
I am one of many people suffering with chronic pain, and I suffer from many types of chronic pain. Many people are in the same boat. It annoys me each and every time I am asked to rate my pain level from 1-10. My reply is always the same. It’s just not that simple. I tell the medical assistants, nurses and providers “a better system for rating pain needs to be put in place, especially for those who have multiple types of pain and in multiple areas. Better treatments need to be found to manage pain.” Unfortunately it seems to fall on deaf ears. The numbers 1-10 mean nothing, and your right, providers do not have the time to discuss patients pain. It is such a huge problem that is being overlooked, and in a huge way it is because there are few, if any, viable pain management solutions that work. Not only that, having 10 minutes with a provider is never enough. Some of the reasons diagnoses are hard to come by is because: 1) Not enough time is spent with the patient. 2) Notes are getting lost in the computer, and providers do not have time to review prior notes or reports at each visit, therefore pts are constantly restating the same symptoms at every visit. 3) Drs write what they want and rarely what the pt reports. 4) Drs are struggling to find reports they know they have, because they are either misfiled, or it’s just too time consuming to search for them. 5)Once the pt leaves the office, it’s “out of sight, out of mind”. Diagnoses are not being pulled together until it is too late, often many yrs later (as in my case). It’s an ongoing repetitive cycle, and it’s actually causing more visits and wasted money all the way around (for the pt, the dr, the insurance co’s and the govt). 6) There are less and less trained drs and nurses. Pts are forced to see more and more less experienced medical assistants, physician’s assistants, nurses aides and nurse practioners.
I myself have many types of chronic pain and have few answers: One day, or one hour, neuropathic pain and eye pain may be more prominent, soon after bone, joint, and burning, stinging, itchy skin pain is more prominent, and suddenly GI pain and inflammatory, skin tightness pain may be more prominent. There is no rhyme or reason, but it hurts a lot, is very annoying and is severly affecting my quality of life. Here is a list of some of my pain types: 1) Neuropathic Pain, 2) Eye pain 3) Skin Pain 4) Stomach Pain 5) Multiple Joint Pain 6) Muscle Pain 7) Bone Pain 8) Gyn Pain 9) Inflammatory Skin, Blood Vessel, Muscle, Mucous Membrane Pain, etc 10) Scalp, Neck and Facial Pain 11) Hands, Wrists, Arms, Feet, and Ankles Pain 12) Tendon and Ligament Pain.
That is why asking for a Pain Score of 1-10 does absolutely no good at all. The numbers mean nothing. A better approach is needed as well as better pain management. We patients want a better quality of life. Also, we need much quicker diagnoses.
I am not a fan of Opioids either. I have been down that road. Eventually, it doesn’t work any more, especially if you’ve been prescribed them for many years. I took myself off them. I was getting sicker and sicker, and in more and more pain, and had no answers. Drs will not keep increasing your dose, and that is not the answer anyway. NSAIDS, gave me serious stomach problems, and Tylenol doesn’t touch many types of pain. AntiDepressants only help neuropathic pain a little, and have many side effects. AntiConvulsants have many side effects as well. Topamax gave me involuntary muscle movements and had to be stopped immediately. Gabapentin was prescribed prophylactically for migraines but made my headaches worse. I was I told to stick it out, keep taking them and it would improve. It only got worse the longer I took it. I had an allergic reaction to Lyrica and ended up in the E/R. My spine was treated with steroid injections 4x a year for many years. That too is not the answer. Steroid Injections also have been known to cause many problems.
We need better pain management treatments, and providers need to listen to the patient. We’re the ones with the pain. Providers are so used to hearing about pain, and it is so common that our complaints tend to go in one ear and out the other. They need to consider all the patients symptoms, and not just look at the signs. This is often overlooked. Science needs to do more studies on pain and pain management. We need quicker “DIAGNOSES”, providers who “LISTEN”, and BETTER PAIN MANAGEMENT! Opioids helped the most for me, but opioids shouldn’t be used long term. They are not the answer. Scientists need to look at why and how opioids work, and find treatments, with less side effects, that stop those same pain channels. Also, better neuropathic pain management is also needed. People are suffering from all types of pain and are sent on there way. Autoimmune diseases are not being addressed. My father had RA, Diabetes, Thyroid problems, Angina, Gout, and much more. He died much too young, and after suffering for many years. The stress on caused by chronic pain only exacerbates the problem. It affects and declines any person’s physical, emotional, mental, financial and social health even further. Perhaps we need another physician specialty, AutoImmune Specialists? Ill health brings on further ill health because there are no answers, and no one has the time. Last but not least, Religion and state should not be separated. That’s more than half the problem. Over-prescribing medications is also a big part of the problem, and in my opinion is actually causing more and more disease.
That’s enough I guess. I hope this message gets passed on to a superior govt health care official who has a caring heart, understands PAIN is a severe inhumane problem many are dealing with that needs addressing, discusses this with upper management, and takes action on this huge problem.
Thank You,
L H
Dear LH, thank you for being so clear and descriptive about the complexity of chronic pain. I’ve suffered with chronic headaches for 30 years and have tried it all. Now after 30 years of Extra STrength Excedrin every 4 hours of every day, the inevitable reflux and esophageal ulcers must be treated and so it goes. But my experience is NOTHING in comparison with my 27 year old son’s. He tore out both knees in high school football and after 4 surgeries was prescribed hydrocodone post surgery each time and titrated DOWN to tramadol…which for the past 10 years has been handed to him like water…now, of course, he is addicted, and rather than help him deal with the addiction that overdosing has created….the health care system has ‘labeled’ him and cut him off. Where is the ‘do no harm’ in that?
Janet B.
I also have had a constant headache for over eighteen years and have tried nearly all medication to get some relief. I have found the Excedrin Extra Strength is the only medication that will give me relief. I also am worried about stomach problems from taking so much Aspirin. Have you found anything else that gives relief from your headache?
Thank You.
Larry H.
Dr. Collins- Discussing different types of chronic pain and our evolving knowledge on differential pain management is sorely welcomed! Is there precedent to renaming an entire category of drugs (in this case anticonvulsants and antidepressants) given that we now know they are even more broadly effective than those primary indications? The stigma and fear attached to these drugs can be a major barrier for chronic pain sufferers. Likewise, if not offered a “stronger opiod pain killer” without being told that evidence shows for certain conditions these actually aren’t effective but NSRIs are, patients may feel their doctor doesn’t believe their pain is physical and severe. This blog post is exactly the type of patient and provider education effort that could change that! 🙂
Here’s my issue…..
If these so called doctors, would actually listen to you, and care about treating you … not make you wait, weeks upon weeks for testing for this… testing for that…. going to a specialist , waiting weeks to months to get in to see them.
I’ve had chronic right sided back pain, into my butt and down my leg, that is completely debilitating. It started 5 days after I had brain surgery… I’ve been tossed around to orthopedic dr’s, pain management dr’s, neurologist, back to neurosurgeon’s, I’ve had to wait 4 weeks to get an appointment just to have 1 test done. Meanwhile this has been hoping on since October 2013…. all this time… I’ve been living on and have tried every pain pill made, they have tried all the ” psych” drugs for nerve pain… nothing works… if treatment and care were streamlined, and doctors actually cared about finding the cause and fixing things. The use of this crap would be minimal…. not everyone wants to be taking these drugs… i hate it….
And it’s the government that has made it difficult for people who are in actual pain to get the medication they need , when they need it. Several times I have had issues getting prescriptions refilled, with . . . having to have an actual written prescription. … people who have chronic illness and pain ( and in my case , can’t walk and am in a wheelchair at 41… have to go back to the Dr every 30 days just to get a new script, if there’s an issue at the pharmacy like they don’t have that particular kind (capsules/ tablets) then you have to wait days for it to come in, or go back to dr office and get a new prescription for whatever type the pharmacy has in stock. .. they can’t just call the dr and change it… plus heaven forbid you want to refill your prescription more than 3 days ahead of time, because you can’t get someone yo drive you to doctors and pharmacy, they won’t fill it.
Much like gun control…. we have catered to the scum bags that abuse things …. make it harder for the people who really need it … and yet the idiots who abuse drugs and don’t even need them, will still find their way to get them, all the while people like me will end up in tears at the pharmacy (yesterday) because they didn’t have the correct form (capsule/ v tablet) and the dr wasn’t in office and couldn’t even call in the switch, even if they could.
I can attest that Jennifer’s comment is very accurate. Drs have stopped testing, and they drag out the entire process of diagnosing the root cause for many, unnecessary and unbearable yrs for the pt. The pt is forced to go from specialist to specialist and providers don’t want to make a move. I have had many discussions with providers, and I read up on this topic a lot because of the insanity in health care today. Insurance companies are not paying the providers, and providers (and sometimes pts) are stuck with the bills. Insurance companies are coming up with excuse after excuse for the reasons they are not paying. Providers do not want to order testing because they are not getting paid, even for ordered blood tests. They are being told the test was not necessary. I always read every one of my health insurance claims and it baffles my mind what I read. Many drs bill for svcs at exorbitant costs when they know the services don’t warrant the amts billed. And insurance co’s underpay or don’t pay at all for claims billed. It is very unfortunate that pts must go to appt after appt after appt, and nothing ever gets done, no testing, no deep discussion, no trust, no honesty, and they say very little to the pt. We pts go prepared with qstns (as we should), but drs do not answer our qstns and prolong our agony, pain and suffering until the injury, disease or illness becomes so severe we end up in the e/r or ICU.
Conditions are not being diagnosed until far too late, if at all, when the damage done is now irreversible. If you go on any trustworthy website, like NIH, MS, Amerian Cancer Society, Sjogrens Foundation, etc, etc you will read just “how important it is to get diagnosed early”. They even tell you the proper tests that are needed. But drs don’t listen and they do nothing, no matter how prepared you are, until it’s too late.
Jennifer was right about being disabled and unable to get to the drs mo every mo (due to needing a ride), and also not being able to pick up prescriptions when WE are able to get a ride to the pharmacy. I myself have had similar issues. I no longer take pain meds (but I am still in pain). When I did have to go to the dr or pharmacy every mo to pick up my prescription it was very difficult to arrange rides on the exact day I needed to get there, often times I had to be late, and therefore I was out of medication. Also, drs bill for a full visit, when picking up a prescription, and often times we don’t even see a dr when picking up prescriptions. I would go in, see a nurse for 2-3 minutes, and she handed me my regular monthly prescription and sent me on my way. YET, the dr billed the insurance for a full appt?? Does anyone see what is happening here? They are billing unnecessarily and wasting huge amts of insurance money, and they are wasting huge amts of the pts money as well.
If drs started listening, and took action and accurate notes (per the pts symptoms as well), in addition to the few words they choose to write (often inaccurately) about the signs they see on that particular day, they might lessen their appt load. I don’t know how many times I have read drs notes that were grossly inaccurate (hundreds of times) and none of what I stated was in the notes. Yrs ago this was not the case. Many times drs report all systems were normal, when in fact THEY NEVER TOUCHED MY BODY, NOR TESTED ME IN ANY WAY. (Abdomen soft and tender, reflexes normal, tongue midline, temp normal, etc, etc) They don’t even touch you anymore. Enough is enough!!
IF DRS LISTENED WITH BOTH EARS, DISCUSSED THE PROBLEMS AT HAND, BELIEVED THE PT, AND TESTED IMMEDIATELY, both the pt and the dr just might get the answers they need. STOP MAKING US SUFFER and STOP WASTING MONEY!
I, like Jennifer and many others, DO NOT want to be on pain meds. What we want is the correct diagnosis, and promptly, and a chance to recover ASAP. LISTEN, TEST, RESEARCH IF NEEDED, IF NO ANSWER AFTER THEIR FIRST HUNCH, MOVE ON TO THE NEXT IDEA AND TEST. FIGURE OUT THE ACCURATE DIAGNOSIS, AND TREAT AS HOLISTICALLY AS POSSIBLE.
So much money is being wasted on repetitive drs appts going nowhere. DO IT RIGHT THE FIRST TIME AND DO IT EXPEDIENTLY. It just might open appt slots to see more pts, and pts just might get the answers they need and have a much better chance at recovery. DOES ANYONE HEAR ME IN THE MEDICAL FIELD? I must add again before I go, God is the ultimate healer. Put Him first. It does help.
L H
I have been the recepient of the incompetent un researched TMJ “treatment” that oral surgeons unleashd on unsuspecting patients in the 80s. I never had TMJ i was overdiagnosed and prescribed surgery as the only option a Viteck implant. The best relief I have found was with craniosacral osteopathy and craniosacral therapy. I live with a reduced bite and jaw malfunction thanks to the stupidity of these so called TMJ “treatments” but i have relatively little pain due to ongoing therapy with my cranio therapist. Getting movement into the tissues and sutures that can no longer move aleviates stresses caused by the day to day events such as eating and talking that can tire and stress the compromised muscles and tissues in those operated sites I have also had increased movement and opening from this work.. More research needs to be done on methods such as these that will not harm the patient either through chemical overload or surgery and appliance machinations that are unproven, expensive and often make the problem much worse. The cut and burn medival practices that these oral surgeons use and the overuse of “pain” meds that do more harm than good needs to be carefully looked at. And wholebody approaches of movement and tissues and body work need to be researched and supported as a viable treatment option.