The Painkiller Paradox
First in a three-part series on opioid addiction.
In a landmark move, the United States Centers for Disease Control and Prevention (CDC) recently issued a list of 12 new recommendations for prescribing opioid medications. The unprecedented guidelines are a first from a federal agency to establish ground rules for primary care clinicians to reduce the risk of addiction and curb the opioid epidemic sweeping the country.
In an effort to balance pain management patient safety, the CDC’s recommendations include opting for nonpharmacologic approaches and non-opioid therapies—such as ibuprofen, antidepressants and anti-inflammatory drugs—rather than morphine, methadone, hydrocodone, oyxodone and other opioid medications for patients outside of active cancer treatment, palliative care and end-of-life care.
“We hope that these guidelines will provide a standard that providers can look to that will improve the treatment of pain in the United States, and encourage providers to look at other options in addition to opioids—some of which may work better than opioids in a lot circumstances,” said Debbie Dowell, M.D., senior medical advisor for the Division of Unintentional Injury Prevention at the CDC and lead author of the new guidelines. “We haven’t used the full array of treatments for pain in the last 15 to 20 years [because] we’ve relied on opioids increasingly and have forgotten some of the other treatments that may work just as well or better—and certainly have less risk of overdose and opioid use disorder.”
The country has maintained a long history of overprescribing opioid medications. According to the CDC’s most recent study, approximately one in five patients with non-cancer pain or pain-related diagnoses are prescribed opioid medication by doctors. Although the number of opioid prescriptions are high among pain medicine, surgery and physical therapy and rehabilitation patients, approximately half of those prescriptions are dispensed in excess through well-intentioned primary care providers—so much so that, in 2012, health care providers issued 259 million painkiller prescriptions, which was enough to supply each American adult with a bottle of pills, based on a report by the American Society of Addiction Medicine’s 2016 report on opioid use. By 2013, about 1.9 million people in the country reported abusing or being dependent on prescription opioid pain medication in that year alone, according to the same report.
The new guidelines offer a glimmer of hope for reducing opioid abuse, but prescribing restrictions could also have less-than-savory consequences, particularly in the potential uptick of patients with painkiller addiction turning to illicit drugs, and fueling a current trend in illicit drug use, namely heroin.
“In terms of illicit drug use, heroin is the darling,” said Matt Feehery, chief executive officer of the Memorial Hermann Prevention and Recovery Center, whose organization treats approximately 200 patients daily who suffer from substance use disorders. “If those people don’t go out and get help for their dependence or their addiction, then they’re turning to the streets or black market to buy heroin to replace the prescription drug they can’t obtain legitimately.”
Prescription opioids and heroin use are undeniably linked, with 94 percent of people suffering from opioid addiction admitting that heroin was a far more affordable and accessible alternative to prescription painkillers, according to a 2014 survey published in the Journal of the American Medical Association. Running about $1 per milligram, a single 60-milligram pill of prescription painkiller would cost $60 for the uninsured, so it comes as no surprise that people graduate from highly addictive prescription opioids to heroin for one-fifth of the price and 15 times the potency.
“People have that dependence, that need to feed the addiction,” Feehery said. “Their brain needs that drug. They want that feeling. That’s how the drive gets people to cross the line and go from a prescription medication, like Vicodin or oxycodone, […] to take heroin.”
The discussion of the country’s widespread prescription painkiller habit is undoubtedly nuanced, hitting at multiple levels of health care and government policy, but the guidelines, in addition to President Barack Obama’s recent announcement in March to fight opioid and heroin abuse, serve as overdue first steps in addressing a long-established epidemic.
“I think it’s a great start, but it’s almost a little too late,” said Alok Madan, Ph.D., director of the Pain Management Program at the Menninger Clinic and McNair scholar. “If you look at best practices, what the CDC has put out, we’ve known for awhile. We just didn’t have the political will to actually push forward.”
There’s insufficient evidence to show that prescription opioids have any long-term benefits in improving chronic pain, function and quality of life, but their rampant use has been deeply ingrained in the country’s approach to chronic pain management since the 1990s.
“We looked at how effective [opioids] seemed to work for acute pain and relief of suffering at the end of life. There were some small studies looking at a small number of hospitalized patients with chronic pain who seemed to do well on opioids,” Dowell said. “There was a lot of optimism, a lot of hope, that these medications could work for the long term as well as we’ve seen them work for the short term, but I think our optimism got ahead of the evidence.”
With the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) push to improve pain management standards and assessment in 2001, health care providers were encouraged to document high levels of unrelieved pain and lift barriers in the health care system that prevented patients from receiving medication. The report essentially supported the use of opioid medications and downplayed the serious risks studies have since corroborated.
“Health care professionals […] have inaccurate and exaggerated concerns about addiction, tolerance, respiratory depression, and other opioid side effects, which lead them to be extremely cautious about the use of these drugs,” the JCAHO report stated.
“Pain essentially became the fifth vital sign,” Madan said. “I think what we’re seeing today is the pendulum just swinging completely in the opposite direction from there. We might have gone a little too far with that.”
Madan leads a team of specialized clinicians at the Menninger Clinic to help treat patients suffering from chronic pain, using a combination of nonpharmocological interventions—including
cognitive behavior therapy, experimental brain stimulation technologies and genetic testing—with physical therapy, exercise and non-opioid medications. But because chronic pain is characteristically accompanied by comorbidities, such as depression, simply treating the symptoms rather than the cause can exacerbate the condition, prolong medication and risk drug use disorder.
“You’re in chronic pain, so you can’t do as much as you did. You start getting frustrated, you start getting angry, you start getting sad, [and then] you start getting depressed,” Madan said. “Lo and behold, the depression makes your pain worse, so now you’ve got chronic pain with clinically significant depression on top of it. Both are feeding on one another and you’re spending more and more time in bed, you’re not getting out, you’re not even getting sunlight, not bathing, you’re not eating. You can see how this type of situation could quickly spiral out of control.
“I think we have failed in trying the [nonpharmocological interventions] first,” he added. “We quickly go to second- and third-tier treatments, in large part because it can be hard to get patients to go to a physical therapy appointment, while it’s much easier for them to go to the pharmacist and fill up a bottle.”
Prescription opioid medication may provide patients with the path of least resistance, but experts agree that the uncertain benefits of those painkillers come with known risks of addiction and drug abuse, and that physicians should consider nonpharmacological and nonopioid approaches for successful, lasting outcomes.
So while national adoption of the CDC’s new guidelines has great potential to help curtail the opioid addiction epidemic, long-term change requires redefining the country’s approach to chronic pain management and refraining from either overprescribing or underprescribing. Just as Goldilocks navigated through the home of the three bears in pursuit of things that were not too much or not too little, the way forward lies in finding the happy medium of “just right.”