How Do We Treat Addiction and Pain?

Here we have one of the most significant difficulties on the addiction scene, a seeming contradiction of unsolvable problems. The United States is mired in a crippling opioid epidemic, a health crisis which has captured millions of Americans and killed hundreds of thousands of people since the turn of the century.

On the one hand, we need to reduce the opioid epidemic by helping those who are addicted to come down off of drugs through residential rehab. We also need to reduce prescribing rates. According to Move Forward, a division of the American Physical Therapy Association, 214 million prescriptions for opioid medication were written in 2016.

But at the same time, about 100 million Americans struggle with some degree of physical pain, according to the National Academies of Sciences, Engineering, and Medicine, and we can’t forget about them. While it is true that opioid treatment is not going to be the right pain-relief solution for all of those 100 million people, we can’t just take opioid pain relief away from those individuals who are on a pain-management plan without also providing them with another pain-relief approach.

Expert Viewpoints on the Opioid Pain Reliever Conundrum

The issue with opioid pain relievers has the appearance of one of those unsolvable paradoxes. If we considerably reduce access to opioid pharmaceuticals, patients who experience chronic and severe pain issues might not be able to access pain relief. But by that same token, if we continue to accept opioid pharmaceuticals as standard medical practice and utilize them to the degree that we are doing, millions of Americans will become addicted to them, and thousands will die from overdoses on them. That is the brutal truth of the matter.

For several years now we’ve heard the ongoing debate, the never-ending argument between those who support opioid prescribing reduction and those who are adamantly opposed to that strategy. But an interesting opinion piece in USA Today, written by Drs. Alexander and Sharfstein, brings to light the concept that our efforts to address addiction and pain relief do not need to be fundamentally at odds with each other. In fact, we can very well address both these areas at the same time, and with similar strategies.

Embarking on a quest for compromise and resolution begins with first accepting two truths. These are:

• Millions of Americans who struggle with chronic pain and who are prescribed opioids for that pain are at risk of opioid addiction.
• Millions of Americans who do have an addiction to opioid pain relievers are also chronic pain patients (meaning that merely taking them off of their opioid meds without also treating their pain is not a workable approach).

Drs. Alexander and Sharfstein contend that not only are opioid pain relievers risky, but they are overprescribed. According to their writings:

“There is no doubt that opioids have been oversupplied in the United States, with enough prescriptions dispensed in 2010 to provide every adult in the U.S. a one-month, round-the-clock supply of pills…”

“There is no doubt that opioids have been oversupplied in the United States, with enough prescriptions dispensed in 2010 to provide every adult in the U.S. a one-month, round-the-clock supply of pills. Studies indicate that about one in four patients on opioids for extended periods will at some point use them in ways other than as intended, with as many as 10% developing opioid-use disorder, or addiction. For many patients, these risks outweigh the benefits that opioids might provide, as there is limited evidence of their long-term effectiveness for chronic pain.”

That is a fair amount of serious data imparted in one paragraph. To the casual observer, it would seem that opioids should be done away with entirely, and maybe someday we will achieve that goal. But in the meantime, what about the millions of Americans who struggle with chronic, severe pain? How can we treat pain and addiction together?

A New Idea

Dr. Caleb Alexander and Dr. Joshua Sharfstein propose a dual approach to these issues. On the one hand, it is a good idea to reduce opioid prescribing. The truth is that, if doctors are prescribing enough opioids in one year to medicate every American adult for a month, we are overprescribing. There is not enough pain in this country to justify that level of prescribing. So reducing prescribing is a good start.

At the same time, however, we should not automatically pull chronic pain patients off of their opioid medications with no thought for their safety or physical comfort. (Not to mention that a forced weaning down off of opioids without professional help can be dangerous and is very unpleasant.)

Here is what Dr. Caleb Alexander and Dr. Joshua Sharfstein recommend:

• First, provide more than just opioids to patients who suffer from chronic pain. Drs. Alexander and Sharfstein cite physical therapy, over-the-counter pain relief (non-opioid), and other methods of counseling and specialized care for addressing not only the physical pain but the source of that pain. One could also add holistic and alternative methods of pain relief into that approach.
• Second, the two doctors discuss the importance of the medical community getting educated on how to spot opioid dependence when it occurs. If doctors cannot tell between a patient who is taking opioid pain relievers ethically versus one who is taking them unethically, we’re never going to get out of this problem. Doctors have to know what they are dealing with when it comes to pain and opioids so they can make sensible judgments on how best to treat their patients.
• Last but not least, the doctors recommend that insurers and regulators not accept “one-size-fits-all” policies directed towards pain relief, opioid drugs, prescribing, etc. Such methodology helps some and then harms others. The conclusion here is that we have to treat patients on an individual basis, always keeping in the back of our minds the knowledge of how dangerous opioids are, and how they should only be used as an absolute last resort, particularly after other therapies have been attempted.

A compromise like this would likely be the best way to reduce opioid prescribing significantly while also ensuring that pain patients are still receiving help and care.

Sources:

• https://www.usatoday.com/story/opinion/2019/04/25/opioid-epidemic-overdose-treat-addiction-pain-management-prescription-drugs-column/3548434002/
• https://www.ncbi.nlm.nih.gov/pubmed/18574357
• https://www.nap.edu/read/13172/chapter/2
• https://www.moveforwardpt.com/resources/detail/7-staggering-statistics-about-america-s-opioid-epi

Reviewed by Claire Pinelli, ICAADC, CCS, LADC, RAS, MCAP