It was her fifth visit to the Emergency Department in the past month, each time seeking relief from the same gripping abdominal pain. The pain wasn’t new; in fact, despite being only 33, Emily had been suffering from intermittent diffuse abdominal pain for seven years. It all started after the former college gymnastic star had her son and felt overwhelmed. Searching for the cause of her pain, Emily had undergone numerous CT scans, endoscopies, surgeries (appendix, gallbladder, uterus - all removed), and tried multiple medications. The pain got so bad that she became addicted to the Percocet pills prescribed by her primary physician. Tragic stories like Emily’s have become routine, and it is not news that in the U.S. opioid dependency, abuse, and overdose have reached shocking levels. The Centers for Disease Control (CDC) report that overdose deaths from opioids, including prescription opioids and heroin, have more than quadrupled since 1999.1
Disturbingly, overdoses involving opioids killed more than 28,000 people in 2014 and over half of those deaths were from prescription opioids.1 Today, 80% of heroin users started their habit via abusing prescription opioids often prescribed by a well-intentioned practitioner, often for an acute painful condition or injury. In addition to our deadly opioid situation in the U.S., we have experienced a parallel increase in the number of people suffering and/or disabled by chronic (non-cancer) pain. Chronic pain affects an estimated hundred million Americans and costs our nation about $635 billion per year in medical expenses and lost productivity.2
When seeing the scope and trajectory of these two problems, one logically questions how we could have more people disabled with chronic pain today than ever before, despite our dramatic escalation (three- to four-fold increase) in opioid prescribing, pain injections, and surgeries for painful conditions like back, neck, and joint pain.
As a DEA official recently said in a public opioid reduction conference, “We simply can’t play whack-a-mole with this problem.” Essentially he was saying what many of us believe, which is that we need to simultaneously focus not only on the “supply” side but also on the “demand” side of the opioid equation. The question millions of Americans (and their healthcare providers) are now asking is, “If no pain pills, what are we are supposed to do?” The reality is, the two largest national public health epidemics of our generation – chronic pain and opioid abuse/overdose - are closely linked and neither can be improved in isolation without thoroughly understanding and systematically addressing the causes of both issues.
Why is persistent pain so hard to treat?
While there is still much that needs to be elucidated about why and how acute pain transitions into chronic pain, we do know that pain signals can remain active in the nervous system for years after an injury and sometimes even without any identifiable injury. We also know that substantial changes in both brain structure and neurochemical composition are associated with chronic pain. Much of the pathophysiology of chronic pain may lie in these neurocognitive changes which cause the brain to “over sense” routine and non-threatening nerve signals. Muscle tension, limited mobility, and low energy levels often result. Understandable emotional symptoms including frustration, depression, anxiety, and an over-exaggerated fear of re-injury, are common and maladaptive. Such irrational fear can prevent a return to normal life and enjoyable leisure activities and can make the perception of pain worse. Nearly every type of medical practitioner knows that chronic pain is often accompanied by this constellation of symptoms that often don’t respond well to the conventional therapies (e.g., medications, nerve blocks, or surgery) that work to alleviate acute pain. Many believe that at least one major contributor to our system failure to remedy our chronic pain is that too many of us — providers and patients — fundamentally view (and treat) acute and chronic pain in similar ways, when they are in fact very different clinical entities.
A path towards reducing opiate abuse and persistent pain
The latest neuroscience, supported by functional brain MRI imaging suggests that approaches combining not only physical but mental and social factors are more effective in reducing pain and disability. This is likely because pain is, in part, subjective and heavily influenced by our past experiences, thoughts, and emotions. For example, the way in which we each anticipate and react to pain strongly influences when, or even if, we recover from a painful condition. This does not mean that physical pain is not real. It only means that by understanding the entire biopsychosocial aspects of pain, providers can offer more appropriate and effective therapies to their patients. With these insights, “integrative” or “complimentary” practices have increasingly been shown in randomized trials to reduce chronic pain and pain-related disability. Among these treatments are cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR).
CBT, a strategy to recognize and modify unhelpful thoughts and behaviors, has shown impressive long-term results without the risks of medications and procedures. MBSR, a combination of mindfulness meditation, body awareness, and learning to be in the present moment, also shows great promise in reducing pain, anxiety, and improving function. A core principle of treating chronic pain is engaging and explaining to patients the nature of the chronic pain condition, establishing appropriate goals, and developing a comprehensive treatment approach and plan for adherence. Certainly, the basic concept we all learned of primum non nocere applies here. This translates into starting with less invasive, safer, and cheaper therapies before using those with far more potential for side effects. Of course, this necessitates that as a society we each accept responsibility for our wellness as opposed to the passive “recipient of care” model. Such a comprehensive shift in approach is feasible and is already underway in many settings.
For example, Arizona is formally addressing chronic pain as a chronic disease - similar to heart disease and diabetes. Recently, as part of the Arizona Governor’s comprehensive effort to reduce opioid deaths, the Arizona Department of Health Services’ director, Dr. Cara Christ, launched a novel state public health program focused on helping people better understand and self-manage chronic pain without opioids.
This type of innovative public health effort, in conjunction with practitioners taking the time to have these crucial conversations with their patients, along with adherence to prescription opioid monitoring, will simultaneously help stem both the epidemics of opioid-related deaths and chronic pain disability. Unlike almost all previous major public health problems, we - the medical profession - played a role in the evolution of our current opioid and chronic pain problems.
Now we must all do our part in helping turn things around. Some helpful patient resources can be found at The Pain Project What Chronic Pain Is and How to Successfully Manage It
- Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research presents the IOM study – 2011