WASHINGTON — There’s little, if any, debate about using prescription opioids to treat severe acute pain, cancer pain, end-of-life pain or similar conditions. When used wisely, these drugs can spare seriously ill patients from weeks or months of excruciating pain.
Less clear is how these medications should be prescribed to treat chronic pain – for example, low back and joint pain – and in many cases, whether they should be prescribed at all.
Opioids, including prescription medications like OxyContin and Vicodin as well as illicit drugs like heroin and fentanyl, were responsible for more than 42,000 deaths in the United States in 2016, according to the Centers for Disease Control and Prevention. This was five times the number of opioid-related deaths in 1999, which is considered the beginning of the current addiction epidemic and also followed a sharp increase in opioid prescriptions from doctors.
A study recently published in the Journal of the American Medical Association found that during a 12-month period, in patients being treated for chronic back pain or hip or knee osteoarthritis pain, opioid treatment showed no advantage over non-opioid treatment.
Those findings support guidelines from CDC, Erin Krebs, the study’s lead author and a doctor and professor at the University of Minnesota, wrote in an email. The federal guidelines, issued in 2016, advise doctors to use opioids for chronic pain treatment only if non-opioid methods of treatment don’t work.
But determining whether or not a method of treatment “works” is quite difficult, because pain is subjective. Though it’s been called the “fifth vital sign,” treating it isn’t like treating high blood pressure or diabetes, where quantifiable vital measures clearly indicate whether treatment is working. Understanding pain relies on the patient’s own description of it.
Opioid treatment for chronic pain typically lasts longer than a standard three- to seven-day opioid regimen for acute pain. Patients who receive the medications for chronic pain often take them for months or years.
It’s also often the case that when the medication doesn’t work, or when it stops working, doctors respond by increasing the dose level. This leads experts and non-experts alike to question whether the medications actually treat patients effectively, or if an immediate decrease in pain is simply a sign of tolerance to the drug without the underlying cause of the pain ever being addressed.
But this gets into an even thornier issue: How much pain is too much?
“The key to me is whether you want to achieve function or comfort,” said Jane Ballantyne, a doctor at the Seattle-based University of Washington who specializes in pain management. She has argued that the pain intensity a person experiences isn’t necessarily the most effective indicator in determining whether their treatment is effective.
“We don’t have anything that can completely eradicate pain,” Ballantyne said. Rather, she said, patients have to accept some pain. “If you don’t accept that pain is part of the human condition,” then it’s very difficult to treat.
Ballantyne and two colleagues published an editorial in Politico last week arguing in part that most forms of chronic pain “are not diseases, but symptoms of underlying conditions, such as arthritis or diabetes, which we believe are best managed without resort to opioids.”
Like other medical professionals, Ballantyne argues that interdisciplinary treatments – for example, physical and behavioral therapy – in addition to learning how to live with pain are often most useful in addressing it.
But unlike the drugs produced by a multibillion dollar pain medication industry, those other methods of care often lack financial backing and insurance coverage. Ballantyne wishes government agencies like Health and Human Services would sponsor more public advertising campaigns to highlight for patients how chronic pain can best be managed. “They do it on drug abuse and smoking and obesity,” she said, “and why not do it on pain?”
As for the JAMA study, Ballantyne noted that while it had limitations – the study population was limited to patients from Minneapolis Veterans Affairs clinics, and it looked only at back pain and osteoarthritis pain – the findings do support the idea that opioids don’t seem to help many common types of chronic pain.
Charles Argoff, an Albany, New York-based pain management specialist and president of the American Academy of Pain Medicine Foundation, takes a different view.
Population-based studies like the one that Krebs’ team conducted “are not how we take care of people in the real world,” said Argoff. The best avenue of treatment depends on the individual patient, he said. So the best way to tell if a line of therapy – opioid or non-opioid – works might be to see how an individual patient responds to each method. And sometimes, he said, a combination of opioid and non-opioid therapy is necessary.
He agrees that a lack of funding and insurance coverage for certain treatments, like physical and behavioral therapy, means patients don’t have access to all potentially effective treatment options. But he and organizations like AAPM argue in favor of “individualizing care to optimize treatment outcome.”
Still, other experts urge caution. “Every provider should take note that there is no evidence that long-term opioids are safe or effective for pain or function, and now we have evidence to the contrary,” Charles Reznikoff, a Minneapolis addiction medicine specialist, wrote in an email regarding the JAMA study. (Reznikoff, while not involved in the research, did make a point that he knows Krebs.)
He said more research like this study will be useful going forward in helping doctors understand opioid treatment for chronic pain. “We need to keep informed,” he said. “We need to be cautious and humble about our general lack of evidence and how fast the evidence is evolving for opioids for chronic pain.”