A Delicate Dance Between Pain and Prescription

Pain levels are rising and people of lower means and education report more chronic pain, a study finds. New opioid policy might not be the answer.

Ivanka Trump presumably has the president’s ear. So when Massachusetts Governor Charlie Baker found himself seated with her at a National Governors Association dinner Sunday, he took the opportunity to talk about America’s opioid crisis. Baker noted their discussion on CBS This Morning Tuesday.

Can stricter prescription drug policies address rising pain levels?

Visual by iStock.com/txking

The Bay State leader explained how his state legislature’s Democrats and Republicans collaborated to develop a 2016 state law that governors of 46 other states now have “signed on to” as a way to address the epidemic in their regions.

The law has “a lot of elements to it,” Baker told the CBS program, “but it’s basically prevention and education on the front end. Better training of prescribers. I mean, until very really recently you could practice medicine, you could be a dentist, you could be a nurse, you could be a physician’s assistant, and never take a course in pain management or opioid therapy. In Massachusetts anyway, you gotta actually take a course and pass it now to graduate from any of those schools.”

Acknowledgment of pain management needs in the midst of public concern about rising use of prescription opioids likely provides some psychological relief to the approximately 100 million Americans who suffer from chronic pain — the constant companion of people with arthritis, some cancers, back damage, migraines and other conditions.

In 2014, more than 28,000 people fatally overdosed on opioids, including heroin. Increases in heroin use are tied to the misuse of and dependence on opioid pain relievers. Nevertheless, the vast majority of prescriptions for opioids reportedly go to people who do not develop addictions, a fact that can get lost in discussions of the current crisis. And policy crackdowns are already having an effect: the proliferation of opioid prescriptions in the U.S. peaked around 2012 and then dropped in 2013, 2014 and 2015.

The need for more effective pain management stands out clearly in a new statistical analysis based on a nationally representative sample of nearly 20,000 adults over the age of 50 who were surveyed repeatedly from 1998 to 2010. At the start of the study, more than a quarter of respondents reported chronic non-cancer pain. But by 2010, that figure rose to more than one third, according to research published in the February issue of the journal Pain.

And while middle-aged people (ages 45 to 64) are the most likely age group to have pain lasting more than 24 hours, a quarter of people between ages 20 and 44 also reported such pain, according to data from the 1999 to 2002 National Health and Nutrition Examination Survey.

In the longitudinal study, levels of pain rose for each age group over time; in other words, new cohorts entering each age group in the study experienced more pain than did the group they replaced for that age interval.

Pain is more than discomfort — it’s a condition unto itself. And higher levels of chronic pain are associated with earlier death on average, the research reveals. Most striking: social disparities in chronic pain apparently mirror social disparities in health care. People of lower socioeconomic means report significantly more pain than people of higher socioeconomic means. Also associated with higher levels of pain: lower levels of education.

“For instance, if you’re just looking at severe pain, someone who doesn’t have a high school degree is 370 percent more likely to have severe pain than someone who has a graduate degree,” says study author Hanna Grol-Prokopczyk, a medical sociologist at the University at Buffalo. “That is really big. That is something that previous studies haven’t shown because they don’t break pain down into mild versus moderate versus severe.”

Unfortunately, some of our federal policy aimed at reducing prescription opioid overdoses and addiction has little to no basis in evidence and may have become so cautious that it forces doctors to either risk professional suicide by prescribing, or deny pain medications to patients who need them, two physicians wrote last week in the online publication STAT.

A draft policy released last month by the Centers for Medicare and Medicaid Services ratchets down the dosage threshold at which pharmacies can be blocked from dispensing opioid painkillers. This limit could provoke withdrawal and dysfunction among people currently on higher doses for pain relief.

Many research questions surround who suffers from differing pain levels, why they do, how they are treated and the implications for overall health. For instance, Grol-Prokopczyk was surprised to find in her analysis that pain levels among Americans over 50 actually went up as opioid analgesics use rose in the first decade of the 21st century.

“There’s growing evidence that when used in long-term, opioids can increase pain,” she says. “It’s possible that the pain profile of the country was made worse by the widespread use of opioids.”

Clearly, little of what is known about pain and public health inspires confidence in new policy directions regarding prescription opioids. But educating the president’s adult daughter about policies already making a difference was more constructive than demonizing people in need of medical attention.

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2 comments / Join the Discussion

    Thank you so much for this reasonable article about it the “opioid crisis”. It’s refreshing to see the subject explored rationally without the usual hype and propaganda.

    Most of what I see written about this crisis wrongly suggests that opioids cause addiction and ignores the issue of pain entirely. So it’s gratifying to see the acknowledgement that some pain patients need opioids and have no problems with them.

    Scientific research has become just as anti-opioid as the media with studies that are designed only to find more negative effects of opioids.

    In their overzealous efforts to demonize opioids, researchers are confusing the effects of opioids with the detrimental effects of pain:

    http://nationalpainreport.com/opioids-blamed-for-consequences-of-chronic-pain-8832994.html

    Reply

    I have written widely on the current “crisis” in forced reduction of prescription opioid use for people in chronic pain. From 20 years of intensive study and support to chronic pain communities, I challenge Dr. Grol-Prokopczyk on the unsupported and unscientific assumption that prolonged use of opioids in any way “causes” increases in pain levels among Americans over 50. The cause-effect relationship is actually in quite the opposite direction. Opioid prescription levels increase because underlying medical conditions which cause pain are very often progressive in nature, and are more often diagnosed in recent years than formerly. Likewise, chronic pain is most commonly under-treated by physicians who are unaware of the wide variability in natural opioid metabolism in the chronic pain patient population as a whole. These are facts, not suppositions, well supported by published medical literature.

    In this context, the March 2016 opioid prescription guidelines released by the US Centers for Disease Control and Prevention have proven to be an unmitigated disaster for chronic pain patients, and in fact contribute NOTHING to reducing overdose deaths. Doctors are being driven out of pain management practice all over the US. Thousands of chronic pain patients have been dumped “in the street” without referral and often without support for opioid withdrawal symptoms and greatly increased levels of agony. Whole areas of several US States (notably but not exclusively Montana, Tennessee and Kentucky) now lack any pain management center. Published stats from the CDC reveal that as numbers of prescriptions have dropped, deaths from street drugs like heroin, diverted methadone, and synthetic fentanyl have risen — an effect which is not accidental.

    Compounding this debacle, we now know that the methodology used by the CDC guidelines consultants writing team was deeply influenced by unacknowledged anti-opioid professional biases among the writers. When literature was reviewed to assess the effectiveness of opioids, non-opoid medications, and behavioral therapies, the reviewers cherry picked the studies allowed to contribute as “evidence”. They rejected any study of opioids that lasted for less than a year — but did NOT similarly reject studies of alternatives.

    As noted in the journal Pain Medicine, [ref: Pain Med (2016) 17 (11): 2036-2046], “To dismiss trials as “inadequate” if their observation period is a year or less is inconsistent with current regulatory standards… Considering only duration of active treatment in efficacy or effectiveness trials, published evidence is no stronger for any major drug category or behavioral therapy than for opioids.”

    The only ethically and medically sound way forward from the present horrid misdirection of US government policy on opioids is to immediately withdraw the restrictive CDC guidelines and stop their implementation as mandatory in medicare and medicaid reimbursement standards. Rewriting should be led by board certified pain management specialists rather than addiction psychiatrists, and chronic pain patients or advocates should be voting members of the writing team.

    Reply
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