As I said, the curbside consult happened this morning, but conversations with providers like this one has happened countless times in the past. There are two essential aspects to these conversations: 1) a perceived dilemma between the use of opioids for pain in an individual with a high risk of adverse events from the use of opioids, particularly exacerbation of a substance use disorder or accidental overdose or both, and 2) the provider feeling constrained to nevertheless prescribe opioids.
Notice the relative value that treating pain has in these common scenarios. The reduction of pain with the use of opioids is more important than the risk of adverse harm in the form of addiction (or exacerbating an already existent addiction) and death associated with opioids.
Why do providers feel forced to treat pain with opioids?
This sense of constraint comes in part from patients who commonly insist in these kinds of scenarios that opioids are the only therapy that works for them. They report histories of previous trials of various therapies all of which were insufficiently helpful to go without opioids. Thus the unspoken inference is that if pain is to be treated, it must be treated with opioids. From here, we come upon the aforementioned value judgment: both untreated pain and the exacerbation of an active substance use disorder with a high risk of death are unacceptable, but it is more unacceptable to experience untreated pain.
An impetus to this common sense of constraint to treat pain with opioids is the assumption that opioids are the most effective form of pain management. It’s a commonly held view in society, but it isn’t necessarily true. In 2018 a meta-analysis (Busse, Wang, Kamaledin, et al), which is a study combining previous studies to make one big study, and typically thought of as one of the gold standards for determining scientific findings, found that opioids for pain were associated with a small, less than one point decrease in pain on the zero to ten scale when compared to a placebo. The authors noted that while the finding was statistically significant, it was not a clinically significant difference in pain reduction. Moreover, they found no difference in pain reduction when comparing opioids with non-narcotic pain medications. Also, in 2018, Krebs, et al., found that those who managed moderate to severe chronic low back, hip or knee pain with opioids had less reduction in pain than those who managed their pain with non-narcotic options. Moreover, those using opioids had significantly more adverse outcomes. In 2019, a two-year prospective study comparing matched controls between those who managed chronic pain with opioids to those who didn’t and found no difference in pain, physical functioning, emotional functioning, or social functioning (Veiga, Montenero- Soares, Mendonca, et al.).
In all, what these studies show is that the use of opioids for moderate to severe chronic pain does not add value over and above non-narcotic medications or non-pharmacological methods for managing pain. They are not more effective and they are associated with greater risks of addiction and death. As such, they also cast into doubt the benefit-risk ratio that we have tended to make – the known risks of harm in terms of addiction and death outweigh the known levels of pain reduction that the medications produce.
Non-pharmacological methods to manage moderate to severe chronic pain are also more effective than opioid management. Specifically, chronic pain rehabilitation programs, sometimes also referred to as functional restoration programs, have long been known to provide greater pain relief than opioids (Du, Hu, Dong, et al, 2017). Indeed, such programs are so successful that patients taking opioids are able to stop taking them and still have significantly less pain than when they were taking opioids.
One might explain to patients, such as the one in the above described consultation, that for their condition there are both pharmacological and non-pharmacological ways to manage moderate to severe chronic pain that is more effective than opioids. This discussion should come to patients as relieving – there is hope that doesn’t have to come at the risk of iatrogenic harm!
So, why does the insistence on treating pain with opioids continue? Why do we maintain the sentiment that pain reduction with opioids is more important than the associated risks of exacerbating an already known addiction and its likelihood of accidental death?
Stigma of Addiction
There are many ways to define stigma and the Institute has discussed many of them. One way to look at stigma is in the relative value that we place on health conditions when comparing them. This issue lies in the background or context of clinical decision-making, but it can subtly determine or influence clinical decision-making within a busy clinic setting. Conditions that tend to be stigmatized are those that tend to have less value than other conditions. Value itself can be defined by the degree of education providers receive in their training, or the degree of attention that is provided to it in a busy clinic setting where time is itself in high demand. Thus, stigma might underlie these value judgments in terms of how important a condition is or deserving of time and attention.
We can see such subtle influence in the not uncommon practice of providers to readily prescribe opioids to those with a brain disorder of addiction despite being loathe to prescribe acetaminophen to those with a renal disorder. Similarly, providers might commonly ask patients whether they have ever had a history of gastrointestinal bleeding before prescribing ibuprofen, but just as commonly refrain from asking about a history of addiction prior to prescribing opioids. What makes renal and gastrointestinal bleeding disorders more important than a brain disorder of addiction? This subtle relative value difference is typically long-standing in the careers of providers, where one commonly received significantly more education and clinical training in the former conditions than the latter condition. As such, the typical provider simply has a greater level of expertise and comfort with renal and gastrointestinal bleeding disorders than brain disorders. This fact remains true more generally for all physical health, as compared mental health, conditions. This distinction of value between physical health versus mental health conditions is evident in how the provider in the above described consultation felt compelled to emphasize that the patient in question has a ‘real medical condition’, as if by affirming its reality it becomes somehow more deserving of attention and treatment than the not-so-real brain disorder of addiction that the patient also has. Thus, the reduction of pain can become more important than the reduction of addiction.
Another way stigma can influence clinical-decision making when it comes to the relative importance of reducing pain or addiction and death is that pain is easier to discuss than addiction and the potential for accidental overdose. While all three topics are commonly emotional topics, addiction and accidental overdose are more emotionally sensitive topics. They take greater degrees of time, energy and emotional intelligence on the part of the clinician. In a busy clinic setting where the next patients to be seen are already awaiting their turn to be seen, pain and its reduction can be the path of least resistance as opposed to the more complicated and time consuming focus of how to reduce both pain and addiction and accidental overdose.
How important is pain reduction -- revisited
We started this discussion with a story about a primary care provider consulting me over a dilemma that she faced – a provider who feels constrained to treat pain with opioids despite a known opioid addiction and its risk of accidental overdose and death. However, we actually don’t have a dilemma between reducing pain and reducing iatrogenic addiction or death when it comes to moderate to severe chronic pain. We don’t have to continue the practice of reducing pain with opioids at the cost of iatrogenic addiction and death. We need to dispel this sentiment, because it just isn’t true. We have multiple ways to manage moderate to severe chronic pain that are at least as effective if not more effective than opioids, all of which come with less risk of harm.
It’s a pretty good deal and it’s time that we, as healthcare providers and patients, accept that deal more often.
Busse, J. W., Wang, L., Kamaleldin, M. et al. (2018). Opioids for Chronic Noncancer Pain: A systematic review and meta-analysis. JAMA, 320(23), 2448-2460. doi: 10.1001/jama.2018.18472 Video: https://www.youtube.com/watch?v=qWADk7lr6wA
Du, S., Hu, L., Dong, J., et al. (2017). Self-management program for chronic low back pain: A systematic review and meta-analysis. Paient Education and Counseling, 100(1), 37-49. doi: 10.1016/j.pec.2016.07.029
Krebs, E. E., Gravely, A., Nugent, S., et al. (2018). Effect of opioid vs. non-opioid medications on pain-related function in patients with chronic back pain or hip or osteoarthritis knee pain: The SPACE randomized clinical trial. JAMA, 319(9), 872-882. doi: 10.1001/jama.2018.0899
Veiga, D. R., Montenero- Soares, M., Mendonca, L., Castro-Lopes, J. M., & Azevedo, L. F. (2019). Effectiveness of Opioids for Chronic Noncancer Pain: A two-year multicenter prospective cohort study with propensity score matching. The Journal of Pain, 20(6), 706-715.
Date of publication: October 6, 2020
Date of last modification: October 6, 2020
About the author: Dr. Murray J. McAllister is the publisher and editor at the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported and to make that empirically-supported pain management more publicly acessible. To achieve these ends, the ICP provides scientifically accurate information on pain that is approachable to patients and their families.