The number of opioid prescriptions, while still very high, has gone down since 2010. The problem is, the number of patients with chronic pain has not gone down. Data from the NIH show 1 in 10 people in the U.S. experience chronic pain. We seem to have more chronic pain patients in the United States, and their subjective view of the intensity of their pain actually is worse. At the same time, we are suffering from an epidemic of opioid use disorders, and the overprescribing of opioids is likely one of the factors fueling the epidemic.
We are faced with an important question: How can we help people adequately manage their ever-worsening chronic pain without inadvertently furthering the opioid addiction problem?
The Center for Disease Control (CDC) released guidelines in March of 2016 based on a review of the published academic literature on different strategies for managing chronic pain. To sum up the CDC’s findings, it found no evidence that opioids were effective for managing chronic pain. The CDC did find evidence, however, that alternative strategies -- such as cognitive behavioral therapy, acupuncture, medical massage, physical therapy -- were useful in providing relief for chronic pain.
The Difference Between Acute Pain and Chronic Pain
Pain is a subjective problem. If your foot is aching, for example, pinching yourself on the arm will act to deaden your body’s perception of the ache in your foot. Also, different people experience pain differently. An injury one person might shrug off is an excruciating experience for another.
The definition of chronic pain is a pain condition that lasts for more than six months. Less than six months, it’s considered subacute pain. It’s something of an arbitrary cutoff, but it’s a workable definition.
If you look for a more functional definition, there have been studies involving brain scans of patients who have experienced years of chronic pain. What’s interesting is that the parts of the brain that are activated in those people are the same areas that are activated in emotional disturbances. Basically, chronic physical pain becomes emotional pain. That’s an important understanding, because we take a completely different approach to intervention with people in chronic emotional pain, involving psychotherapy and experiential therapy and avoiding intoxicants and psychoactive drugs like opioids. We know this works for emotional pain; the idea that it might work for chronic physical pain is exciting.
Why the CDC Recommended Against Opioids for Chronic Pain
While dealing with pain can be very subjective, the CDC took an objective look at the effectiveness of different treatments for chronic pain. The measurements the CDC was looking for in its review were: reduction in pain, ability to function with respect to activities of daily living, and quality of life.
While the definition of chronic pain is pain that lasts six months or longer, the CDC found that almost all the studies for medications that are used for chronic pain were less than six weeks in duration. In other words, the studies didn’t actually measure the impact of opioids on chronic pain -- and the results of these studies really weren’t applicable to chronic pain therapy.
When doctors prescribe a medication, they must take into account the risk of adverse side effects. Opioids carry a tremendous risk of addiction, with a 15-fold greater risk for those who have been taking opioids for three or more months. The CDC also found many of the strategies that pain management practices had adopted to mitigate the risk of opioid addiction were also not effective. Many pain clinics would assess people for risk of addiction, have them sign a medication contract, educate them on the risks of the medication, perform urine drug testing, undertake pill counts, or use abuse-deterrent formulations of medications. All these actions are intended to prevent addiction, but the CDC found no studies showing whether these efforts made any difference in preventing addiction.
Balancing the risks against the benefits, the CDC concluded there was slim evidence for the usefulness of opioids in chronic pain.
At the same time, the CDC looked at treatments with non-opioid medications -- things like non-steroidal anti-inflammatory drugs (NSAIDs), anti-depressant and anti-seizure medications -- and therapies that didn’t involve drugs at all -- cognitive behavioral therapy, exercise therapy, and physical therapy -- and interventional approaches such as having an anesthetic or an anti-inflammatory steroid block. The CDC found that there was evidence that those modalities were effective for chronic pain.
“Extensive evidence suggests some benefits of non-pharmacologic and non-opioid pharmacologic treatments compared with long-term opioid therapy with less harm.”
That’s a pretty strong endorsement for using non-opioid drugs and alternative methods. Now we just need for the medical community, and the healthcare insurance companies, to catch on.
Alternative Pain Treatments are Not New
The effectiveness of alternative treatments for chronic pain has been known for a long time. There were a large number of multi-disciplinary pain clinics opened on a somewhat experimental basis back in the early 2000s, where patients would come in and see a physician, a physical therapist, a psychologist, a massage therapist, an acupuncturist, etc., all under one roof. These practices were very successful in alleviating pain in chronic pain patients, as the CDC later confirmed, but the idea wasn’t widely adopted because the approaches were expensive and insurance companies didn’t want to pay. Opioids were cheaper. Unfortunately, we now know opioids don’t work.
Those of us involved in addiction treatment have long known about the effectiveness of using these other modalities in combination. This is the approach we take at Caron for patients that have substance use disorder and chronic pain. And, it works. The wider practice of medicine is just catching on to the fact that opioids are not the appropriate long-term strategy for managing chronic pain, that a better approach is to use a combination of alternative modalities.
These alternatives take time and effort, though. It’s much more time-consuming to get a massage, receive an acupuncture treatment, or undertake an exercise regimen than it is to just go to the doctor and get a prescription. Often these alternative treatments aren’t covered by insurance, which continues to be a barrier for patients. But, these treatments work.
Using Alternative Methods to Manage Chronic Pain Successfully
There really isn’t any secret to using these methods effectively. They just need to be done, and they work best when done in combinations. The trick comes when a patient is already using opioid analgesics to manage their chronic pain. That can be a very difficult transition -- and there are a few approaches that make using these other approaches more successful in managing chronic pain.
Completely stop using opioids. When we suggest using these modalities to patients who are using opioids to manage their chronic pain, often the response is, “Oh, I’ve already tried that and it didn’t work.” When I hear that, I respond by asking, “Were you taking opioids when you were trying these alternatives?” The answer is always yes.
All of these other alternative modalities are much more effective once somebody is off of opioids. I can’t explain why this is so, but I suspect it has to do with the pathways that these methods use to promote pain relief. For example, yoga therapy is helpful for some people with chronic pain, but it bypasses our body’s built-in opioid system altogether. It works through a completely different mechanism. My guess is, when the opioid system is activated, it just doesn’t allow these other pain relief systems to work as effectively.
Connect with others who are also managing their chronic pain. I run group therapy sessions for people who experience chronic pain, where people are able to talk about their pain with other people who have similar issues. This seems to be extraordinarily helpful. Again, I can’t really explain why, though I suspect, since chronic physical pain is experienced by the brain as a form of emotional pain, sharing this pain, and having other people listen and truly understand, somehow
makes the pain less burdensome.
Manage the transition in an inpatient setting. In my experience in transitioning people from an opioid-based pain management strategy, having them in an inpatient environment is crucial. There’s usually a rebound increase in the pain experienced when the opioids are stopped. It is a form of opioid withdrawal, where the pain is felt intensively. But, after a few weeks, people are usually dramatically more comfortable. The inpatient setting can be helpful in getting through what is a difficult transition; people doing this on an outpatient basis don’t fare as well.
We Can Do Better
My understanding of chronic pain has matured drastically in the years that I’ve been treating those with chronic pain who also suffer from a substance use disorder. It is my belief that chronic pain is a biopsychosocial condition very much like addiction. That’s why the treatments are so often complementary, and that’s why they overlap so well.
I used to be hesitant in talking about this, because I felt it was important to be in alignment with the standard thinking on pain management. I didn’t want to look like too much of a heretic. The problem is, the longer I do this, the more I believe the standard thinking about chronic pain management is just wrong. Over the next ten years, I would expect research will find additional non-pharmacological modalities of treating chronic pain and that we will have a whole new comprehension of what chronic pain is and how to deal with it.
If you have a chronic pain condition and the mainstay of your treatment is with opioid medications, you can do better. You can get better relief without as many side effects. It will require an investment of time and effort, but, in the long run, you will be happy that you made the change. If you have a chronic pain condition, and you’re not satisfied with how things are going, challenge your doctors to see if there is a better approach.