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14 Articles in Volume 18, Issue #9
Assessing Arthralgia in Children
Children, Opioids, and Pain: The Stats & Clinical Guidelines
How to Fit into a New Practice
How to Talk to Your Chronic Pain Patients
How to Treat Opioid Use Disorder in Pregnant Women
Intranasal Ketamine for Acute Pain in Children
Medication Selection for Comorbid Pain Management (Part 3)
MR Neurography: Using Peripheral Nerve Imaging as a Pain Diagnostic
Naloxone in Schools; Buprenorphine Conversions; OUD Management
Opioid Conversion Calculations and Changes
Pes Anserine Tendino-Bursitis as Primary Cause of Knee Pain in Overweight Women
Self-Management of Chronic Pain in Primary Care
The Homebound Adolescent: Managing Chronic Pain Conditions in the Pediatric Population
The Opioid Band-Aid: The State of Pain Pills, Congressional Bills, and Healthcare in the US

The Opioid Band-Aid: The State of Pain Pills, Congressional Bills, and Healthcare in the US

A Guest Editorial with UW's Heather Tick, MD
Pages 6-8

Opioid prescriptions are starting to decline but the deaths are increasing anyway. News headlines are awash with concerns for the crises of opioids and addiction. The federal government recently passed a package to try to deal with opioids. Missing from most conversations, however, are other, more troubling issues: the growing problems of poorly treated pain, undertreated mental illness, and general declining health in America.

Opioids and addiction are symptoms of more fundamental system failures—not the primary cause of poor health in America.

The "Healthy" State of our Nation

The US population continues to drop in its ranking of health compared to other developed nations and, yet, its healthcare system is the most expensive in the world. Our country has steadily lost ground since the 1950s compared to longevity and health among other wealthy nations.1,2 We now have three decades of research and reports from the Institute of Medicine highlighting the dangers of our healthcare system—medical errors are the third leading cause of death in the US—and its inability to keep the population healthy.3-6 How did we slip so far down that ladder? How have we, a resourceful and clever people, not been able to fix these shortcomings in more than 30 years?

The current business model of medicine, including the hospital systems, insurers, and pharmaceutical companies, may shed some light. On a flight to Canada a few years back, I sat next to a very nice businessperson with whom I shared a commonality: our daughters are swimmers. After sharing swimming stories, I found out that he was a consultant to many of the largest pharmaceutical companies in the US. Since we were having a congenial conversation, I decided to ask him a question that had been bothering me for several years. Early in my career, it seemed that pharmaceutical companies were working to develop solutions to health problems that sick people had. More recently, it seemed they were trying to market drugs that were already developed, to healthy people. I asked, “Is that true?” He answered, “Well of course it is… It is a terrible business model to have to wait for people to get sick!”

I was a little surprised that he was so candid, but there it was: in a corporate climate where bottom-line finances are the be-all-end-all, the system just wants more customers and will sacrifice health to get them. This attitude may explain why we have not heeded three decades of data on a failing health system; it would have been bad for business. A healthy population provides fewer customers for all aspects of healthcare.

Band AidDisease management strategy can be likened to applying bandaids rather than addressing root causes, says the author. (Source: 123RF)

Mismanaging Side Effects with More Medication

And so the system has allowed Americans to become addicted to drugs—and not just opioids. The fact is that most non-life-saving medications do not, in fact, make us healthier, but they do come with a high price of risky side effects. As a simple example, ibuprofen and its NSAID relatives kill more than 16,500 Americans every year.7 When NSAIDs cause heartburn, ulcers, and bleeding, people turn to antacids, mostly proton pump inhibitors, or PPIs, which the FDA warns, cause serious health problems when used for more than 3 months. NSAIDs aid symptoms but do not solve the underlying problems which are usually related to diet and lifestyle habits. In the long term, these serious side effects led the FDA to warn, “The risk of heart attack or stroke can occur as early as the first weeks of using an NSAID."8 This is just one situation where the drug changes physiology and causes dependence, including withdrawal symptoms when patients try to stop taking them. Individuals often end up staying on these medications for years and sometimes decades, and their side effects end up being treated with more medications, which may further damage health. We are addicted to the notion that medications can overcome all unhealthy habits and solve health problems when mostly they treat symptoms in a piecemeal way.

Opioid Prescribing Gone Askew

When the pain care community initially looked for solutions to treat patients with chronic pain, it was considered normal to seek pharmaceutical solutions. Opioids were marketed as a non-addicting way of providing patients with relief—a worthy goal, but alas, an unattainable one for most chronic pain conditions. The US ended up prescribing 50 times more opioids than the rest of the world combined in its attempt to eliminate pain. Yet, being totally “pain free” is usually not possible or even desirable, as I learned when working as a hospice doctor. Even though pain medications are liberally dispensed at the end of life, many patients decline to take enough to be pain free because they want to maintain their level of awareness and connection to their loved ones.9

Opioids have not lived up to their promise of pain relief without harm—and they cannot. These medications become less effective the longer they are used. Higher doses are needed and patients lose sight of what their pain would be without them. Surprisingly, it turns out that as individuals who were once on high opioid doses wean down or even totally off of opioids, they often report the same or reduced levels of pain. The process of withdrawal is very unpleasant, but the end result is usually better function. The research is clear: there is no good evidence that daily opioid therapy works for chronic non-cancer pain and there is very strong evidence that it interferes with a return to health and carries a high risk of harm.

There has been a growing recognition that people with chronic pain often also live with depression, anxiety, post-traumatic stress disorder (PTSD), sleep disorders, and more serious mental illnesses. It has also been shown that patients with more severe forms of psychological distress tend to be the ones who get on the highest doses of opioids and are, therefore, at greater risk of addiction and death.10 It is another sad fact that getting treatment for pain is easier in the US than finding insurance covered treatment for psychological disorders. In cases where individuals are in despair, opioids have been a stand-in for mental healthcare.

Where Should We Seek Solutions?

The evidence increasingly demonstrates the need to build health and resilience. We know that lifestyle factors – what we eat, drink, think, feel, and do – have more impact on our health outcomes than genetics. Strategies that encourage patients to become active partners focused on making healthy choices rather than remaining passive recipients of piecemeal disease management show more promise than new drug development.

An important study of tens of thousands of people examined lifestyle factors and health and found that healthy choices dramatically reduce the numbers of heart attacks, strokes, diabetes, and cancers in ways that medical and drug therapies cannot hope to match.10 Many of these diseases are associated with pain and have the same underlying root causes as pain conditions. This phenomenon has been referred to as “healthy living is the best revenge."10

There are many non-pharmacologic therapies for pain that are underutilized and not covered by insurance despite evidence that they work both in the short- and long-term. Therapies such as acupuncture, massage, osteopathy, chiropractic, Tai chi and yoga, mind-body therapies, and nutritional improvements (see more on nutritional pain management in our AIPM highlights) are often safe and effective for reducing pain; some studies have shown that these approaches have long-term general health benefits even 12 months after the therapy ends.

Of particular interest is their ability to improve mood and anxiety. A recent whitepaper on evidence-based non-pharmacologic pain care by the Pain Task Force of the Academic Consortium for Integrative Medicine and Health, consisting of 72 medical schools and health systems, noted that some of these treatments were shown to reduce the need for opioids after surgery for acute, chronic, and cancer pain.11 The belief that conventional care is more proven than non-pharmacologic alternatives has been shown to be false.12,13 Of course, all therapies need to be judged by their effectiveness, short- and long-term safety, low cost, and acceptability to patients.

Much of current disease management strategy can be likened to putting band-aids over abscesses instead of addressing root causes. If we go back to the lessons learned about opioid addiction from the Rat Park experiments,14 providing opportunities for an interesting and healthy life discouraged the development of addiction in test animals. The greatest impact on overall health has been shown to derive from improving the major determinants of health: the lifestyle factors. The next greatest impact can come from reducing our dependence on conventional medical practices that remain the third leading cause of death.

In the end, the flaws of our pain care system are the flaws of the healthcare system itself. There is an urgent need to stop looking at the problem from the rearview mirror and recognize it for what it is: the opioid and addiction crisis are symptoms of the healthcare crisis in America and efforts to address them separately have little chance of success.

Last updated on: December 3, 2018
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