Where Did the War on Pain Go Wrong?
Opiates have been available, in one form or another, for thousands of years. While varied recreational, spiritual, and medicinal uses have continued over time, the drug’s mode, delivery, and function have been modernized.
In the past 30 years, the therapeutic use of opioids has undergone several major shifts. The 1980s were characterized by fear of opioids and addiction even among patients being treated for cancer, which resulted in concern for the undertreatment of pain. In turn, a low risk of addiction in cancer patients was used to justify prescription opioids for chronic noncancer pain.1 Throughout the 1990s, support for opioid use for chronic pain grew among pain specialists, professional societies, and various organizations until opioids for chronic noncancer pain became the standard of care.
The Federation of State Medical Boards endorsed the move in 1998 in its model guidelines, which were updated in 2004.2 Substantial increases in opioid prescriptions were also fueled by the Joint Commission requirement for pain to be assessed as a vital sign in every encounter—the fifth vital sign.3
From 1999 to 2010, prescriptions for opioids increased by 400% and, unfortunately, this trend was accompanied by a corresponding increase in prescription opioid overdose deaths.4,5 The increase in deaths associated with opioid abuse and misuse could, in part, be considered the unintentional result of a sincere intent to treat pain.
Chronic opioid therapy has now become a political target and a treatment dilemma for clinicians and patients alike. Overprescribing and overreliance on opioid therapy are key concerns, but the root causes are multifactorial. Many attribute the current crisis to the aggressive marketing of newer extended-release opioid formulations. While expectations that the formulations would reduce misuse and abuse ultimately proved false, such marketing campaigns may continue to influence and misinform physicians in the absence of dedicated evidence-based pain education and core competencies.
Professional education, or lack thereof, is another factor. Currently, less than 3% of medical schools incorporate pain management into their curriculum, yet chronic pain is the most common reason patients see a provider, and it accounts for 40% of all visits in primary care.6 In a survey of primary care providers, 73% expressed frustration with treating chronic pain patients, and 38% were dissatisfied with their ability to treat pain.7 Limited time for patient encounters and provider frustration can easily lead to increasing prescriptions for opioids or refusal to treat pain due to fear of regulatory reprisals or mistreatment. With 40 million Americans living with moderate to severe pain daily, and an aging population, an investment in education and training will be required to meet the demands of current clinical practice.8
The Institute of Medicine’s 2011 report “Relieving Pain in America” reminds us that despite over a decade of focusing on its treatment, pain remains a significant public health burden ($635 billion annually) that warrants a cultural transformation in prevention, care, education, and research.9 Among the National Institutes of Health’s recommendations in its National Pain Strategy, released in March 2016, is that “chronic pain is a biopsychosocial condition that often requires integrated, multimodal, and interdisciplinary treatment, all components of which should be evidence-based.”10 Both reports endorse interdisciplinary and multimodal approaches to pain management that, despite the highest level of evidence supporting improved outcomes, have all but disappeared in the US outside of integrative health systems due to lack of reimbursement by managed care organizations.11,12 Similarly, reimbursement for evidence-based therapies like cognitive behavioral therapy, acupuncture, chiropractic, massage, and physical therapy are often not covered, decreasing pain patients’ access to tools proven to reduce reliance on opioid therapy while improving functional outcomes.13 It doesn’t seem surprising then that prescription opioids have increased dramatically, since alternatives to pain medications and procedures are limited.
Several assumptions borrowed from cancer pain have had a negative impact on chronic noncancer pain management. The risk of addiction in chronic pain patients was underestimated because duration of cancer pain, diagnosis, and treatment does not correlate with the length of exposure in chronic pain patients. Long-term exposure to opioid medications, in particular, increases the risk of opioid use disorder.14 However, in patients with no personal or family history of addiction, no systematic review has shown a risk of addiction greater than 3.27% in the chronic pain population.15
In addition, the undertreatment of pain has led to the accepted adage, “Pain is whatever the patient says it is,” which encourages assessment and treatment of pain but often is misinterpreted as justification for opioid therapy without appropriate diagnosis or pathology. Even in the treatment of cancer pain, a diagnosis identifying a potential cause of severe pain is necessary to receive any medication therapy, including opioids. Similarly, the concept that opioids have no “ceiling effect” has led to high-dose opioid therapy limited only by side effects, and has resulted in an ever-growing body of evidence showing that long-term side effects like sleep apnea and hypogonadism are dose-dependent.
Perhaps opioids will always be synonymous with pain management, but we got here by allowing opioids to become a central treatment focus without considering other medications and treatment modalities.