Now that we know that the pharmaceutical companies are being punished for their role in the opioid crisis, we can all relax and know that things are going to be ok, right? Not so fast. We know that the pharmaceutical industry behaved like selfish monsters pushing pills on doctors, pharmacists, and patients creating a deadly national health crisis. State legislatures respond with new laws restricting access to the drugs in the hopes of stemming the large number of deaths. The medical community is retraining doctors and staff regarding the prescribing of opiates. But these are only first steps in addressing the opiate crisis. Just as trying to put out a forest fire with a simple bucket of water provides only temporary relief, reducing the number of opiates prescribed only begins to address the crisis. There would not have been a market for the pills if there wasn’t a large contingent of patients with chronic pain. A Center for Disease Control study in 2016 found “an estimated 20.4% of U.S. adults had chronic pain and 8.0% of U.S. adults had high-impact chronic pain.” That is over 50 million Americans experiencing chronic pain with 4 million in high impact chronic pain. Why are we not looking more closely at other methods for managing chronic pain? As long as there are people in chronic pain, we will have people who are understandably looking for a way to escape the pain. Providing alternative methods and funding for more research into dealing with chronic pain would address one of the root causes of the opiate crisis.
Simply limiting the availability of opiates does not help those in pain. When patients seek medical treatment for their pain, doctors prescribe all types of drugs and treatments beginning with the least potent and then moving up the scale to opiates until the pain is alleviated. However, for chronic pain patients, the pain does not subside. If they are taking opiates, they need a larger and larger dose to get the pain level to decrease leading to addiction and for many, abuse.
While we do not know exactly how the pain signals work in the brain, theories of chronic pain indicate that the brain signal for pain is in a permanent “on” position. Chronic pain affects patients’ mental health leading to severe depression around the normal life they have lost and anxiety about the return of pain. Patients frequently have to stop working due to their pain. This causes major disruption to their lives both emotionally and financially. They lose their health insurance and most have difficulty getting approved for disability. Their pain removes them from activities with friends leading to isolation and depression. Anxiety builds as they wonder and worry about whether they will ever be able to live a normal life again. Anxiety around the duration and intensity of pain is a constant. If they do get to a place where the pain is manageable, and they are ready to return to the workforce, they need support there as well. Explaining gaps in work history without revealing their medical history and falling behind on skills are just two common issues patients face.
What would a comprehensive pain treatment program look like? The Department of Health and Human Services commissioned an interagency task force to devise an all-encompassing plan for dealing with chronic pain. Their recommendations emphasize using a biopsychosocial approach of interdisciplinary professionals for treatment. The multi-disciplinary team including a Primary care provider, an Addiction specialist, a Pain clinician, a Nurse, a Pharmacist, a Psychiatrist, Psychologist, Physical or occupational therapists, and other possible behavioral health treatment specialists (e.g., social worker, marriage and family therapist, counselor). With all of these different specialties involved, we can see why having them all at one facility would make it easier and much more likely for patients to keep their appointments and participate in their therapy.
We can look at a model example. The Mayo Clinic has a Comprehensive Pain Rehabilitation Center that serves patients on an outpatient basis. The program lasts for three weeks and patients attend daily for 8:00 am-4:00 pm. If the patient is addicted to opioids, the first order of business is to address this issue. They offer Cognitive Behavioral Therapy, physical and occupational therapy, biofeedback, and Mindfulness-Based Stress Reduction. While the program is not designed to eliminate pain, it is meant to help patients better manage their pain. According to the Mayo website, “Of patients who complete the three-week program, 84 percent report better pain control despite discontinuing pain medications.”
Perhaps the biggest advantage of a comprehensive pain program is that the patient does not have to go to four or five different places for care. Her psychiatric, medical, and pharmaceutical care is all in one place. The medical professionals working with the patient work as a team, communicating about progress on a regular basis. Compare this to a patient seeing individual providers in their individual offices working in silos. For those disabled by pain, having one place to go instead of getting rides to five different appointments is a gift.
In my home state of North Carolina, there are some promising programs like the Integrated Chronic Pain Treatment and Training Project in the western part of the state. Work began in 2016 with goals including: Education about the potency of opioid medications and the potential for misuse, group medical visits that provide social connection and support, ways for patients to change their perception of pain (ways to endure pain and stay active), screenings to identify behavioral health issues such as prior substance abuse or trauma, and referrals for patients who would benefit from more intensive treatment. One of the barriers included difficulty with staffing in the clinics in the most rural corners of the state.
While state and federal legislatures focus on laws regarding the disbursement of opiates, they must also provide funding for innovative research into chronic pain management as well as for facilities that offer a comprehensive approach to pain management. Until chronic pain patients have options other than opiates, the problem will remain. Getting to the source of the problems is of paramount importance if we truly want to see significant improvements.
A shorter version of this article was previously published on www.womenadvancenc.org