Medicine must do good for people living with chronic pain

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AAs a medical student, the Pain Lens helped me begin to see patients as people – discerning their stories, examining their bodies, understanding their lives, and more. In medical schools around the world, the first simulated patient students encounter to imitate the rituals and mannerisms of medicine is a person in pain. Still, chronic pain, especially one that doesn’t emanate from a broken bone or an inflamed appendix, seemed like a distant, fuzzy concept to me.

That changed when, one day while exercising, I heard a loud click in my back and the metal bar I was holding with 200 pounds of weight crashed into my chest, pinning me to the bench.

Fourteen years later, I still live with the aftermath of that incident. While I initially feared this injury would end my medical career, it then indelibly shaped how I view others in affliction, giving me hard-earned insight into the plight of the 50 million Americans suffering. of chronic pain, many of which the medical establishment has harmed through acts of commission and omission.

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A story that a friend and colleague told me illustrates the miserable state of those who suffer relentlessly and the difficult choices faced by their doctors. Joe (pseudonym) suffered from chronic back pain like me, and although he saw many doctors, he really connected with my friend, a primary care doctor who had just finished his training. Joe was taking OxyContin for his pain, but was following all the rules these patients are supposed to follow: he never ran out of a prescription sooner than he was supposed to, never flooded the clinic with phone calls requesting refills, has never exhibited behaviors that would give him the dreaded label of “drug-seeking patient.” However, his pain worsened and my friend, noticing Joe’s good behavior, reluctantly continued to increase his dose of opioids, which seemed to allow him to live his life as he pleased.

When Joe moved to California three years later, the new doctors he connected with were horrified by the high dose of OxyContin he was taking. Worried that he might overdose, they started reducing his dose. Although this caused Joe to retire, his new doctors did not change course. Joe turned to heroin he could get on the street, and soon died of an overdose.

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This story, which I shared in my new book, “The Song of Our Scars: The Untold Story of Pain,” encapsulates America’s sordid entanglement of chronic pain and opioids.

In the 1980s, doctors were so afraid of opioids that they preferred not to prescribe them, even to people suffering from excruciating pain related to cancer. Calls to improve pain treatment, such as urging clinicians to include pain as a fifth vital sign (along with body temperature, heart rate, respiratory rate, and blood pressure), have made clinicians less fearful of pain. aggressive use of opioids.

At the same time, companies like Purdue Pharma were bringing to market a new generation of painkillers that they claimed were not addictive.

This toxic union has led millions of Americans to become addicted to opioids. Between 1999 and 2019, 500,000 people died from opioids, with a record 75,673 deaths between April 2020 and April 2021.

As the medical community has finally been made aware of the dangers of these drugs, aggressive and sometimes clumsy attempts to cut painkillers, like what happened to Joe, have led many chronic pain sufferers to embrace illicit opioids like l. heroin and fentanyl, which only further increased the risk of overdose. And when the Covid-19 pandemic emerged, the overdose crisis deepened: More Americans died from opioids last year than any other in recorded history. As clinics closed, opioid prescriptions went down, and rehab centers closed, some people may have switched to illicit fentanyl or heroin. Unprecedented job loss and social isolation, the shutdown of harm reduction services, and increased contamination of illicit narcotics with the far more deadly fentanyl may also have swayed many opioid users.

The medical community played a primary role in triggering this pandemic through the reckless prescribing of opioids, so it is fitting that they take responsibility for patients who have been prescribed opioids to treat chronic pain.

While opioids are an almost miraculous balm for acute pain, they are not good therapy for chronic pain. Not only do they have well-documented harms, but they are not as effective in treating chronic pain: an extensive review of studies conducted by the Federal Agency for Research and Quality in Health Care found that opioids are not were no better at treating chronic pain than the safer painkillers. such as ibuprofen or acetaminophen. In fact, a major randomized trial showed that people with moderate to severe back or joint pain who took opioids actually had After pain than those taking safer non-opioid medications.

Why? Opioids actually lower the pain threshold by suppressing the body’s innate mechanisms for relief.

Even with this knowledge, a blunt approach to quitting opioids can be dangerous. A recent study of Medicaid-covered patients found that abruptly stopping opioids is associated with increased deaths and suicides. This risk was not reduced by the fact that these patients were more likely to be prescribed buprenorphine, the drug used to ease the pangs of opioid withdrawal. Yet the same study also revealed the kind of dilemma that patients and clinicians find themselves in: versus those whose opioid dose has been reduced or stopped, those whose opioid dose is stable or increasing n did not do better because they had a greater risk of fatal overdoses.

The risks of a patient continuing or stopping opioids make one thing clear: starting opioids is one of the most important decisions a clinician can make. However, while 76% of American patients are prescribed opioids after low-risk surgery, only 11% of similar Swedish patients take opioids. Even such a short course of opioids can be risky. One study found that for 29% of heroin users, their first opioid came from an emergency room. In 2016 alone, American dentists wrote 11.4 million prescriptions for opioids, a proportion 37 times higher than English dentists. This is particularly important since 5.4% of people who have been given opioids by their dentist develop an opioid use disorder. The irony is that people who were prescribed opioids after a visit to the dentist actually report higher levels of pain than those who were given non-opioids.

Physicians should be especially careful when starting opioids in patients who research shows are most at risk of developing an addiction: those with a history of mental illness or substance abuse. Yet in one study, patients said they were not given information about the difficult road any chronic opioid patient is likely to encounter. “I don’t know why (clinicians) don’t tell you more about these mediations before prescribing them! one patient told researchers. “It’s like knowledge is power, and they don’t want you to have that power.”

“I needed to explain this to myself in simple terms,” ​​said another patient, “…rather than saying here are your pills, see you later.”

Stopping opioids or reducing the dosage without offering the patient adequate resources or alternatives can be dangerous and can break the patient-doctor relationship even if done with good intentions.

The Veterans Health Administration (VA), a health care system in which I work, offers a model on how to do it right. Between 2012 and 2020, the VA reduced opioid prescribing by 64%. The reductions achieved in the high-risk categories were even more marked: an 87% reduction in patients who were prescribed opioids and benzodiazepines together, which can be a particularly lethal combination; and an 80% reduction in the number of patients on very high doses of opioids.

The fact that VA provides access to the gold standard in chronic pain care – interdisciplinary pain management – ​​which offers evidence-based therapies such as exercise, acceptance and engagement therapy and hypnosis, in addition to procedural and pharmacological options, underpinned these safe reductions. . While most VA facilities offer multidisciplinary pain management, this type of service is in decline elsewhere. Accredited interdisciplinary pain rehabilitation programs nationwide have fallen from 1,500 to 2,000 in the 1990s to just 74 in 2022, including 17 in Texas.

Health care must recognize its role in overdose-related deaths. But solemn reflection is not enough. Unless patients have interdisciplinary pain management options, deprescribing opioids is nothing more than an abdication of responsibility.

Interventions like physiotherapy have helped me survive my own encounter with chronic back pain. Far too many others haven’t been as lucky as me. To recalibrate how clinicians treat patients in relentless agony, they must adopt an approach grounded in empathy, with broad access to the myriad of tools – including opioids if needed – that can safely help. people in extreme circumstances.

Haider J. Warraich is a physician at the VA Boston Healthcare System and Brigham and Women’s Hospital, assistant professor at Harvard Medical School, and author of “The Song of Our Scars: The Untold Story of Pain(Basic books, April 2022). The opinions expressed here are his own and not necessarily those of his employers.

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