Succinctly put, it occurs in the following all-too-common scenario:
- A patient on long-term opioids reports that his or her severe pain would be intolerable without the use of opioids and becomes threatened by open discussion of reducing or tapering opioids, even when the discussion proceeds in a professional manner with caring and empathy.
This all-too-common scenario leads to two contradictory treatment considerations among patients, providers and the greater society, depending on how the phenomenon of intolerability of pain on long-term opioids is understood.
Some will look upon the intolerability of pain as solely a function of pain severity. In this manner of understanding, pain occurs wholly independently of the use of opioids. It’s a common sense understanding: pain is intolerable because it’s severe, and only because the pain is severe; the use of opioids is what keeps the intolerably severe pain at bay. With this understanding of the patient’s pain relative to the use of opioids, many consider the only right thing to do in terms of ethical and humane practice is to continue opioids and even increase them should the severity of pain break through the alleviating properties of the present opioid regimen.
Still others understand the intolerability of pain in the patient’s case as evidence of harm by the opioid therapy itself and thus consider cessation of opioid use as the only right thing to do. By this way of understanding, the severity of pain plays only a partial role in its intolerability. The intolerability of pain is also due to the additional long-term exposure to opioids1, 2, 3 and the likely effects of this exposure on the central nervous system,4 which changes the perceived tolerability of pain. In other words, both the patient’s belief in the intolerability of pain without opioids and the related fear-based response to the possibility of opioid reduction are functions of opioid dependency. Succinctly put, these cognitive and emotional perceptions of pain are not commensurate with solely the pain itself, free of its potential influence by opioid-induced changes to the central nervous system.
Rather, they are a function of how opioid dependency lowers pain thresholds, leaving patients increasingly vulnerable and thus fearful of pain. In this view, opioid dependency is a secondary contributor to the overall experience of pain as intolerable.
As a result, opioid tapering, when done with caring and empathy, and in an interdisciplinary fashion, is an exposure-based therapy that leads patients to overcome their perceived intolerability of severe pain and the resultant fear-based vulnerability to pain. In their stead, patients with severe pain become an empowered self-manager of their pain. In comparison to maintaining patients in a persistently dependent, fear-based state on long-term opioids, the benefits of opioid tapering make tapering the only right thing to do, in terms of ethical and humane practice, when the intolerability of severe pain is conceptualized in this manner.
Herein lies the current state of practice within the field of chronic pain management: two contradictory treatment considerations both espousing to be the most ethical, humane practice – one maintaining patients with persistent, severe pain on long-term opioids and the other tapering the very same patients.
Epistemology as ethics
The conviction that severe pain is necessarily intolerable has held a firm position over the last two decades within the movement to treat chronic pain with long-term use of opioids (and now the proponents of medical cannabis make this very same assumption as well). Indeed, it’s seems an easy viewpoint to assume: the belief that severe, persistent pain is intolerable without the use of opioids seems epistemologically self-evident. Severe pain, it seems, is synonymous with agony or suffering. Once this synonymity is assumed, it becomes an imperative to get rid of the pain by any means necessary. The only apparent alternative is to allow people with severe pain to suffer in agony, which, of course, is unacceptable. As such, treatment with opioids becomes a moral imperative.
No doubt such reasoning forms the basis for the high level of sensitivity that comes with the use of opioids, either as a patient or as a provider who espouses the use of opioids. From this perspective, it can be hard to even understand how anyone might hold a contrary perspective and advocate for the withholding of opioids. Any such advocacy brings with it an immediate rejoinder, bordering on doubt of the advocate’s sense of humanity: “What, you want people with severe pain to suffer?”
Of course, in this view, the only other possible explanation for advocating a taper or withholding of opioids is disbelief that the pain is as severe as the person says it is. Indeed, commonly, those of us who recommend self-management over opioid management for those with severe, persistent pain are accused of disbelieving patients or, worse yet, stigmatizing them as weak in their inability to tolerate pain. A common rejoinder in these cases center on something akin to “You wouldn’t be able to cope with this pain either!” Notice the operating assumptions here: it’s self-evidently true that severe pain is necessarily intolerable and to suggest otherwise is simply to engage in some type of offensively critical value judgment.
Despite its appearance as morally suspect, is it invalid to assert that it’s possible to have severe pain and tolerate it – and tolerate it so well that one can work and engage in other valued life activities, all without opioids?
Pain severity and pain tolerability: Distinct phenomena?
These arguments against the recommendation to taper or otherwise withhold opioids border on ad hominem attacks. Of course, those who advocate for tapering opioids are, or at least should be presumed to be, well-meaning. Most providers who engage in tapering opioids in the process of helping people learn to self-manage pain instead aren’t in it to make people suffer or stigmatize them.
Nonetheless, are they misguided in their belief that severe pain doesn’t have to be intolerable?
The historical clinical evidence would suggest that they are not. Tapering opioids for those with persistent, severe pain has had a longstanding history within pain management. Certainly overshadowed over the years by the rise of opioid management for persistent pain, interdisciplinary chronic pain rehabilitation programs (CPRP’s) have been tapering people with severe pain from opioids for about four decades.5, 6 CPRP’s are an interdisciplinary, cognitive-behavioral and exercise-based therapy that exposes patients with persistent pain to what they have long avoided through the use of opioids (or other means, such as reduced activity). In the process, the CPRP’s show patients how to self-manage pain and increase activities in a work-like schedule of therapies. As a result, patients taper opioids and learn how to maintain a weekly schedule of activities. In learning, they moreover regain confidence that they can successfully self-manage pain and return to work at the same time. Instead of opioid management, CPRP’s, as stated previously, have been teaching patients to successfully self-manage severe pain and return to valued life activities for the last four decades. Various meta-analyses over these four decades testify to the empirical effectiveness of such programs.7, 8, 9, 10 These studies repetitively show that participation in a CPRP allows for the cessation of opioid use, while mildly reducing pain, and significantly increasing functioning.
While facing declines in numbers over the years that correspond to the rise of opioid management,11 many healthcare systems across the Western world continue to have interdisciplinary chronic pain rehabilitation programs. Some systems, such as the Veterans Affairs and the Mayo Health systems, are even expanding the number of such programs. The state of Minnesota recently moved to increase access to such programs through their Medical Assistance program.12
Patients in such programs, after having managed their pain for years on opioids, come to find that they really can learn to self-manage pain – they become empowered self-managers of their severe pain. Initially, it’s a threatening experience to let go of the opioid medications and expose themselves to pain, for the doubt lingers that they’ll experience nothing but intolerable suffering. With caring, empathy and expertise, the staff of CPRP’s coaches them to increasingly face their pain in a gradual opioid taper and learn to self-manage it instead. In so doing, patients learn how to successfully self-manage severe pain. However, just as importantly, they learn to overcome the fear of giving up their dependency on opioids in an empowering experience of taking back control of their lives. In other words, they learn that successfully self-managing severe pain is possible. Anecdotally, one of the most common comments upon discharge is “Why didn’t anyone ever refer me to this program earlier?”
In both the empirical evidence (as evident by multiple meta-analyses cited above) and the anecdotal evidence of the last four decades, CPRP’s produce successful, independent self-managers of severe and persistent pain.
It must, therefore, be possible to self-manage severe, persistent pain and do so successfully. As such, perhaps it’s not so misguided to conclude that severe pain isn’t by necessity intolerable. Suffering and agony are not the inevitable result of managing pain without opioids.
If learning to self-manage severe pain through a concerted effort of interdisciplinary training is possible, isn’t it preferable to maintaining people with severe pain in a vulnerable and fearfully dependent state on opioids? Indeed, doesn’t it become a moral imperative to alleviate such dependent vulnerability and arm patients with the health literate skill sets that allow for successful self-management of severe pain?
Population based studies of self- and opioid management of pain
Studies on the effectiveness of CPRP’s, such as those cited above, have been published for years and yet the belief that severe pain is necessarily intolerable without opioids remains widespread among patients on opioids and providers within the healthcare system. Obviously, publication of empirical evidence to the contrary is insufficient to dispel the belief that without opioids severe pain inevitably leads to suffering and agony.
Epidemiological studies of pain severity and opioid use, over the decades of the rise of opioid management, are pertinent here. What they show is that only a minority of people with chronic pain utilize long-term opioid management. In a US-based study conducted in 2000-2001, early in the era of widespread use of opioids, Hudson, et al.,13 found that, among people who had moderate to severe chronic pain, roughly 6% were engaging in the use of opioids for their pain. In a later study conducted in 2007, Toblin, et al.,14 found a modestly larger minority of people managing their pain with opioids, even though more than half of all people with pain rated their pain as moderate to severe. In a more recent study performed in 2012, Nahin15 found that about 17% of the US population reported having severe pain on some to most every day. However, estimates of the use of opioids for pain lie in the 3-4% range.16, 17 These data show that throughout the era of opioid management, even at its height, only a minority of people with severe pain manages their pain with opioids.
Data from diverse researchers have clearly shown that this minority of people with severe pain who manage it with opioids have psychosocial vulnerabilities that differentiate them from those in the majority of people with severe pain who do not manage their pain with opioids.18, 19 In a phenomenon dubbed “adverse selection”, an identified risk factor for becoming a long-term users of opioids for pain is having psychosocial vulnerabilities to dependency, with or without aberrant prescription drug use behaviors indicative of loss of control. These psychosocial vulnerabilities are pre-existing or comorbid mental health and substance use disorders,20, 21, 22, 23, 24, 25 lifestyle related medical conditions,20, 23 lower economic status,26 lower educational levels,21 and rural areas lacking access to non-opioid related therapies for pain.26
Acknowledgement of these data doesn’t entail stigmatizing judgments
The striking lesson from these data is clear: managing severe pain with opioids is not the norm. Most people in the general population with severe, persistent pain have the health literacy and psychosocial capacities to cope with pain and do so without opioids. A minority of the people with severe, persistent pain unfortunately do not have such capacities and as a result they become vulnerable to pain once onset occurs and thus susceptible to depending on opioids to manage their pain for them.
Just as we do not, or should not, stigmatize anyone with mental health and substance use disorders, we do not, or should not, stigmatize the identification of psychosocial comorbidities with persistent pain. The appropriate response for healthcare providers and society alike is not critical judgment, but caring and empathy.
From this light, we can better understand the belief that seems inevitably associated with opioid dependency: the conviction that pain is intolerable without opioids. For those who do not have the psychosocial wherewithal to self-manage severe pain, opioids must seem a Godsend. This opioid dependency becomes self-referential. Dependency on opioids fosters conviction to the false belief that it is impossible to manage pain well without opioids, thus furthering the need to depend on opioids to manage pain.
In this manner, opioid dependency is not dissimilar to dependency on other substances. Substances, like alcohol, can become the means to cope with adverse life events for those who, due to unfortunate life circumstances, do not have the psychosocial capacities to cope successfully on their own. Once having developed an alcohol use disorder, the thought of accepting ‘life on life’s terms’ without alcohol is a highly threatening experience, which simply further reinforces the need to rely on alcohol to cope with the disturbances of life.
Unlike with opioids, however, healthcare providers and the rest of society do not become susceptible to the alcoholic’s conviction that life and all its problems are intolerable without alcohol. As such, we do not feel compelled to make alcohol available to those with an alcohol use disorder.
Why might we do so with opioids?
Providers in the healthcare system can fall prey to the false belief that severe pain is intolerable without opioids. Since the majority of people with severe pain are independent self-managers of their pain, they do not present for pain management and so healthcare providers do not tend to see them in clinic or hospital. Rather, healthcare providers tend to see only those people with persistent pain who are psychosocially vulnerable to pain and who, in their opioid dependency, assert that suffering and agony is the inevitable result of severe pain. Thus, it is understandable that healthcare providers might come to mutually believe that severe pain is necessarily intolerable and so therefore assert that severe pain requires the use of opioids.
A new moral imperative?
It’s time to recognize that pain severity and one’s personal assessment of pain as intolerable or not are distinct phenomena. Just as pain severity varies across individuals along a spectrum from mild to severe, individual differences in the ability to tolerate pain occur along a related yet different spectrum, ranging from low to high pain tolerance.
The acknowledgement of these individual differences in pain tolerance is simply an observation, not a stigmatizing judgment. Of course, some people do judge, but the fact that they do only means that their judgment occurs in addition to the observation that people vary in their abilities to tolerate pain, even severe pain. Some people struggle to cope well with severe pain while others tolerate severe pain and remain engaged in valued life activities. The appropriate response to these observations is not stigma, but empathy and compassion.
Recognition of individual differences in the abilities to tolerate pain, even severe pain, underpins the clinical- and research-based observations that many people rate their pain as severe, yet do not manage their pain with opioids. They live and work and engage in other valued life activities even though they have severe pain and do not use opioids.
This recognition directly challenges the long-held belief that managing severe pain well is impossible without opioids. This belief has been a mainstay for those who espouse opioid management and it underlies the unrelenting fear of those who are reliant on opioids that agony and suffering will inevitably result if they do not have opioids to manage their pain. When, however, we recognize that many people with severe pain fair well without opioids, we cast the long-standing conviction that it is impossible into a new light. We come to see that as a universal statement it is false. We also come to see that the unrelenting conviction with which this false belief is held may be a function of opioid dependency.
Four decades of care from CPRP’s show that self-managing severe pain is a skill set that can be learned. Everyday, people across numerous facilities and multiple countries come to learn how to self-manage severe, persistent pain and do it successfully. Whereas they were once reliant on opioids out of a fear that suffering would inevitably result from their severe pain, they are now no longer vulnerable to their pain. They have pain, but in an important way they have moved on and are now engaged in valued life activities. In other words, they are empowered, independent self-managers of their severe pain.
From this light, a question compels us to be asked: how can we not encourage people with severe pain and reliance on opioids to follow suit? We do not help people with severe and persistent pain by maintaining them in a dependent state of vulnerability and fear that comes with long-term use of opioids for pain. When we have established, empirically-supported therapies that allow such patients to overcome their dependent state of vulnerability to pain, don’t we have a moral obligation to offer it to them and encourage them to access it?
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