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Published Perspectives on Pain Illuminate the Chronic Pain Treatment Divide

June 29, 2017
In the pursuit of effectively treating chronic pain, opioid opinions vary greatly

Interview with Edward Michna, MD

Pain specialists don’t always agree on the best way to treat chronic pain. When you add the role of opioid pain medications to the conversation, that divide is growing. Two published viewpoints in The Journal of the American Medical Association highlight the differences among physicians who treat complex pain and the barriers that prevent many from providing individualized care.

Physicians may feel like they are being over run by the opioid crisis, but JAMA highlights two distinct perspectives on the current treatment challenges.

More Than One Way to Treat Chronic Pain: A Look at Two Different Viewpoints

In “Management of Chronic Pain in the Aftermath of the Opioid Backlash,” authors Kroenke and Cheville write that “the movement to virtually eliminate opioids as an option for chronic pain refractory to other treatments is an overreaction.”1

Challenging the phrase opioid epidemic, Kroenke and Cheville said only a small fraction of patients receiving an opioid prescription progress to chronic use of the drugs. And, most people who use opioids long term do not misuse or overdose on their medication.

Kroenke and Cheville recognize that opioids are an imperfect treatment, but they believe the crisis-level sensitivity surrounding them is unwarranted. Their overarching argument is that, along with nonpharmacological pain therapies (namely cognitive behavioral therapy), opioids can safely be part of a pain management regimen.

On the other hand, Schneiderhan, Clauw, and Schwenk, authors of “Primary Care of Patients With Chronic Pain,” stress the importance of nonpharmacological treatments to the long-term management of chronic pain.2

“The solution to this crisis is not simply a more responsible approach to the use of opioids but rather a comprehensive approach based on an understanding of chronic pain pathophysiology that emphasizes the patient-physician relationship, shared decision making, non-pharmacological treatments, and selective use of non-opioid pharmacotherapy,” write the authors.

The authors explain that physicians should work with patients to set expectations toward management of pain versus the elimination of pain. Improving function, not completely ridding pain should be the shared goal of patient and physician. And the use of non-drug therapies, such as educational programs, psychological therapies, and exercise programs should be explored over opioid treatment.

Truth in Dueling Perspectives

Practical Pain Management reached out to Edward Michna, MD, director of the Pain Trials Center at Brigham and Women's Hospital in Boston for his thoughts on the opposing viewpoints. He said there’s truth in both articles—and they each address different problems with the current chronic pain treatment landscape.

On one hand, he understands Kroenke and Cheville’s perspective. “My whole philosophy on treating chronic pain is about balance, individual care, and rationality,” Dr. Michna said. “The problem with the opioid crisis and resulting public health issue is we’ve tossed out rationality.”

While Dr. Michna said inappropriate use of opioids occurs, the hysteria and legal issues surrounding their use has created a secondary problem: Primary care physicians are acting on autopilot when it comes opioids. They are not writing opioid prescriptions for anyone, even if the patient is a good candidate.  

Another problem with this approach, Dr. Michna said, is patients are not treated as individuals—a focal point of Schneiderhan, Clauw, and Schwenk’s piece.

An individualized approach, which may include opioids and nonpharmacological treatments, is the ideal approach to chronic pain treatment, Dr. Michna said.

But, in the pursuit of a custom treatment plan that uses a variety of therapies, patients and physicians are often met with coverage gaps by insurance carriers—a big problem toward achieving the larger goal of safe and effective long-term treatment of chronic pain. 

Different Perspectives, Same Path Forward

Despite differing opinions on how to do it, Dr. Michna said ideal chronic pain management starts with setting the right expectations.

“You take a well-educated clinician and patient who is educated in the realities of chronic pain,” he said. “The patient knows the goal is not total pain relief but improvement in function.”

Dr. Michna said the perspectives in the 2 pieces, while different, showcase the knowledge of experts in the pain field—something the primary care community would benefit from learning more about.

“We dedicate so little of our federal research dollars to understanding pain, pain therapies, the long-term use of opioids, and the disease of addiction,” he said, noting that less than 1% of the National Institutes of Health budget is dedicated to pain and pain research, yet pain is the No. 1 reason why patients present to their doctor’s office.

“Our federal bureaucracy is passing laws but avoiding the real problem, which is the lack of education of physicians and patients,” Dr. Michna said. “That widespread issue won’t go away with laws or regulations. It will be a many-year, prolonged process until we solve these issues.”

Last updated on: June 29, 2017
Continue Reading:
A Brief History of the FDA’s Role in the Ongoing Effort to Ensure Safe Opioid Use

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