This morning I was a guest on Central Standard, a program which airs on the local Kansas City NPR station.  The program’s focus was chronic pain.  Over the weekend the host’s producer called to do a “pre-interview.”  One of the questions he asked me was about the relationship between efforts to improve chronic pain care and the opioid epidemic.  My first thought was “strap in” because you’re getting ready to be interrogated about the fact that PAINS continues to advocate for comprehensive chronic pain care, including opioids when necessary and effective, and because I have been openly critical of parts of the CDC’s Guideline for Opioid Prescribing for Chronic Pain.  Although I am agnostic about opioids, on more than one occasion, I have been the victim of what a colleague calls “hit and run journalism” and alleged to be an “agent of big pharma” because of the position I take.  I think we have overused opioids.  I do NOT believe they should be our first line of defense.  I think they are very dangerous medications; however, when prescribed and taken appropriately, they are safe and effective and can be lifesaving.  In addition, I think we don’t know nearly enough about them.  As the producer and I talked, however, I realized that this man was genuinely curious and trying to understand the complexity of chronic pain.   The strangest thing happened; in the process, I had an epiphany that I keep thinking about and I want to share.

Improper Treatment of Acute Pain Leads to Addiction

For at least five years, we have attempted to point out that there is clearly a correlation between efforts to improve chronic pain care which led to more liberal prescribing of opioids and the rise in abuse of and addiction to prescription pain medications.  However, even former CDC Director Tom Frieden, who spent much of his time post-Ebola crisis bringing the opioid crisis to the attention of the federal government and the American public, stated publicly that there is no known causal connection between these two public health issues.  One of the stated goals of PAINS’ newest initiative, No Longer Silent, is to clarify the relationship between opioid prescribing for chronic pain and the opioid epidemic – two critically important public health issues.

During my conversation with the radio producer, it struck me that the real “causal connection” here is the poor or improper treatment of acute pain.

Everyone working on either of these issues is very familiar with the story about the high school football star who wrenched his knee and was given a 30-day supply of oxycontin and died a year later of an opioid overdose or the straight A student who had her wisdom teeth extracted, became hooked on opioids, then shifted to heroin when she could no longer get her opioid prescription refilled and died of an overdose in a back alley.  These are tragic and powerful stories among many other cases related to real life situations which should never be explained away.

However, when confronted with the apocryphal story about the football player, I say, “The untimely death of anyone is tragic, especially that of a child or a young adult, but it is also tragic for people who live with chronic pain NOT to be able to access treatment they need, including medications, because we are trying to contain the opioid epidemic.”  Then I take it another step.  I say, “I know these things happen, and the teenager should probably NEVER have been given a 30-day supply of these powerful meds for a wrenched knee, but we know that for a variety of reasons this has routinely happened.  Then in three or four days, the kid’s knee feels better, but he is scheduled to take the SAT in a week or so and he just broke-up with his girlfriend. His mother is on his backside about his calculus grade, and his boss at the Dairy Queen wants him to take on more hours. AND while taking the opioids, he feels better than he has for a long time. He’s not quite so stressed. So, he keeps taking the prescription, and when it is gone, he gets very resourceful about accessing more medication or street drugs to sustain the euphoric effect of the legitimate prescription.” With proper pain management, I believe the football player’s knee pain could have been managed without exposing him to a substance use disorder, addiction or even death.

Alternatives to Long-Term Opioid Prescriptions

I’m not a clinician, but I have worked in the pain space for a long time now; so, let me stick my neck out and suggest that if opioids had been prescribed for a shorter period of time, if then over-the-counter pain meds had been recommended, if heat and ice therapy had been utilized, if he had distracted himself with music or X-box games while recovering,  if the teenager had stayed off his knee for a longer period of time – even if it meant missing a game or two – and if he had seen a physical therapist, he might be alive today.

The subtitle of the Institute of Medicine report, Relieving Pain in America, is A Blueprint for Transforming Prevention, Care, Education, and Research (emphasis added).  Those of us who served on the IOM committee that produced Relieving Pain talked about the need to prevent chronic pain from occurring by providing better care for acute pain.  However, the 360-page report gives little attention to prevention. In Chapter 2, Pain as a Public Health Problem, there are three pages focused on prevention. The section begins, “Perhaps the most important conclusion that can be drawn from a review of the enormous toll caused by pain relates to the need for prevention.  A public health approach to prevention attends to the external, often structural, factors in the social and physical environments that affect not just individuals but populations. These are the ‘upstream’ influences that shape conditions and behaviors that produce or exacerbate disease. In many instances, pain prevalence could be reduced as a consequence of normal public health initiatives aimed at preventing chronic disease….”

Upstream Influences

It was “upstream influences” that triggered my epiphany. The CDC’s locus of concern about opioid prescribing for chronic pain, in my view, has been and continues to simply be misplaced. It should be focused “upstream” on opioid prescribing for acute pain as a measure to prevent pain from transitioning from acute pain, a symptom associated with an injury, surgery, or disease, to a neurologic chronic disease! After having this “Aha!!” I went back to the CDC Guideline for Opioid Prescribing for Chronic Pain and concluded that the real problem is they are mislabeled!  Objections expressed by many individuals, including myself, and organizations about recommended limitations of dosage and duration of opioid prescriptions would dissipate if the Guideline was directed towards acute NOT chronic pain.

What do you think?