If opioids aren’t the answer for treating chronic pain, what is?
Sarah Crawford, firstname.lastname@example.org
Published 6:00 a.m. CT Jan. 26, 2018 | Updated 8:58 a.m. CT Jan. 29, 2018
Clauw decided long ago that prescribing opioids for chronic pain conditions, notably fibromyalgia, wasn't the way to go. Many other doctors differed.
He’s far less alone today. With opioid addiction and the resulting overdose deaths now a recognized epidemic, more doctors are signing on to his approach or, at least, are prescribing opioid painkillers with more care.
At a time when the Centers for Disease Control and Prevention reports that almost half of opioid overdose deaths in the U.S. involve a prescription opioid, how often physicians should continue to prescribe opioids to treat chronic pain is a highly debated topic.
But if opioids aren’t the answer for treating chronic pain, what is?
COMPLETE COVERAGE: The science of opioids
“There are a lot of drug and non-drug therapies that are known to be effective in chronic pain conditions,” Clauw said. “There are seven or eight classes of drugs that are worth trying in different chronic pain patients.”
Clauw believes classes of drugs including tricyclic drugs, gabapentinoids and serotonin-norepinephrine reuptake inhibitors can be effective, in addition to exercise, cognitive behavioral therapy and other complementary therapies.
'Pain comes from the brain'At the Mayo Clinic’s Pain Rehabilitation Centers in Arizona, Florida and Minnesota, participants in a three-week program aimed at helping patients deal with chronic pain are required to taper off prescription opioid use.
Wesley Gilliam, director of the program and a clinical psychologist with expertise in pain management, said the program acknowledges that there’s a biological contributor to patients’ pain but says that treatment also must address how people think about and experience pain emotionally.
Participants in the program have typically been dealing with challenging chronic pain conditions and have already tried numerous treatments to deal with the problem. The program utilizes occupational therapy, physical therapy and pain psychology to help participants deal with pain and learn to function, even without opioids.
“The average duration of opioid use of our patients is between five to seven years, and despite using those medications, they’re still requiring a (specialized) level of care,” Gilliam said. “What that would tell me is the opioids are not helpful for these patients.”
At the Pain Rehabilitation Center, participants learn how to deal with the multi-dimensional aspects of pain, which Gilliam said include coping with the fear of pain and learning how to function in life, even if that still means enduring some discomfort.
“When I’m hurting, if the thoughts running through my mind are, ‘This is an overwhelming catastrophe, and I’ll never have a positive life, and I’m going to hurt like this forever,’ that in and of itself amplifies the experience of pain and actually disables people, frankly,” Gilliam said.
Instead, Gilliam said people need to change the way they interpret the impact of their pain.
“It doesn’t mean life is over; it means we have to make adjustments. And how do we challenge some of those cognitions and alter how the brain interprets pain? Because pain comes from the brain, and we can change our brain structure to experience pain differently,” he said.
Six months after the program is over, the center's staff members check in with participants to see how they’re doing. About 50 percent respond, Gilliam said, and of the patients who had previously been on opioids, roughly 80 percent reported that they continued to function without the medication.
“All of our data tells us that the patients that taper off the medications in our program do just as well as patients that were not on the opioids to start with,” Gilliam said. “That’s pretty powerful.”
Nevertheless, other doctors still see opioids as being effective in certain situations.
Issue isn't black and whiteDr. Gerald Aronoff, medical director of Carolina Pain Associates in Charlotte, North Carolina, said he sees patients who, when very closely supervised, can go to school, work and function normally while on opioid medication.
“We try to start by combining non-chemical treatments — nonpharmacological agents — with exercise programs, attention to wellness principles, nutritional issues, normalizing sleep patterns, referring when appropriate to alternative medicine treaters,” he said.
Aronoff also uses physical therapy as a significant resource. The goal "is to not only treat the pain itself but the associated emotional distress that we call suffering,” he said.
While most chronic pain patients with non-cancer related pain do not need to be on opioids, Aronoff said, he believes a subgroup of patients can be kept safely on these medications to improve their quality of life, daily functional activities and ability to fulfill social roles.
His philosophy is to be cautious about who gets opioids, screening for risk factors and requiring that patients be seen in person before they receive their prescriptions.
Aronoff also noted pharmaceutical companies have made attempts to make opioids safer.
“They will never be totally safe, meaning that no one will overtake or inappropriately take them or get adverse side effects, but there is increasing development of the abuse-deterring formulation of drugs, the morphine drugs, the oxycodone drugs, the hydrocodone drugs,” he said.
Gilliam agrees that the issue isn’t black and white, and there could be certain people who responsibly take opioids for pain and continue to function well.
“It’s just very difficult to identify those patients,” he said. “I would say they’re in the significant minority.”
That is why his program continues to require patients to get off of opioids and find an alternative way to deal with the chronic pain that limits their ability to enjoy and function in life.
“If you look at the data, what you find is the most impaired patients, the highest risk patients in terms of having depression, anxiety, substance use history, the ones that are expressing the more distress, are on the highest dose opioids,” Gilliam said. “So that causes me to really question what that medication is actually doing for folks.They’re the most functionally impaired, yet they’re on the most opioids.”
According to the CDC, while opioid prescribing rates declined nationally from 2012 to 2016, they nevertheless remained high across the country in 2016.
“In about a quarter of U.S. counties,” the CDC states, “enough opioid prescriptions were dispensed for every person to have one.”
Clauw thinks the tide will eventually turn to result in even fewer patients depending on opioids for chronic pain management.
He just thinks it’s going to take a long time.