The Central Dilemma in the Public Policy Debate over Opioids for Chronic Pain

The single most important concern in public policy debates related to the use of opioids for persistent, or chronic, pain is what happens to people with persistent pain when they reduce or taper the use of opioids. 

In recent years, many governmental bodies (CDC, 2019; HHS, 2019; MN DHS, 2018) have developed and proliferated best practice prescribing guidelines that recommend reducing opioids to at least conventionally agreed upon safer dose levels. The overarching goal of these initiatives is to increase safety in light of the epidemic of opioid addiction and overdose. By recommending reductions in prescription opioid use, in other words, the hope is that fewer lives will be torn apart by addiction and less people will die. 

Despite the apparent admirable nature of these goals of reducing opioid-related addiction and death, the prospect of reducing or tapering opioids for people with persistent pain who manage their pain with opioids is highly threatening. Opioids are often seen as a lifeline to maintaining quality of life. For those who manage their persistent pain with long-term opioid use, the notion of the healthcare system reducing opioids, for patients who currently exhibit no overt indicators of addiction, seems profoundly misguided, if not unjust and cruel. People with persistent pain will be denied the very thing that allows them to live a more normal life. Thus, for those who manage their persistent pain with opioids, advocacy to reduce the use of opioids seems nothing but an action that resigns folks with persistent pain to a life of intolerable pain and suffering. 

The dilemma can be captured thusly: saving lives by reducing opioids can only seem to come at the cost of producing intolerable pain and suffering in the very lives that we are trying to save.

Public policy debate on this topic is replete with advocates on both sides of the dilemma. Adherents of the notion to reduce the number of opioid prescriptions are stakeholders such as healthcare providers, public and private insurance officials, family members of those who have died or become addicted to opioids, and some political leaders. Adherents of the notion that opioids should remain available at high doses for those who need them are patients who manage their pain on high dose opioids, their family members, their healthcare providers who tend to prescribe high dose opioids, and some political leaders.

Is there anyway out of this dilemma?

A step in the resolution of this dilemma might begin with a better understanding of what is possible when having moderate to severe persistent pain. Namely, is moderate to severe pain inevitably intolerable and thus is the use of opioids the only humane response despite their potential harms of addiction and death?

The clinical history of pain management might suggest that pain, even high levels of pain, is not inevitably intolerable. Pain rehabilitation programs have had almost five decades of demonstrated evidence of effectiveness in terms of routinely helping people with moderate to severe pain acquire the abilities to self-manage such pain without the use of opioids. Of course, not everyone who participates in pain rehabilitation programs achieve such results. However, most do. The point here is that, for at least some people with moderate to severe pain who have managed their pain with opioids, they can forego opioids with appropriate treatment,  even when their pain continues. Thus, in these cases, moderate to severe persistent pain is not necessarily and inevitably intolerable.

Indeed, epidemiological data on persistent pain in the general population would underscore this observation. A recently published study looking at data from 2013-2014 found that roughly a quarter of people with severe pain managed their pain with prescription opioids (Nahin, et al., 2019). A previous study conducted in the decade of the 2000’s, when opioids were more liberally prescribed, found only a modestly higher percentage of people with moderate to severe pain using prescription opioids for the management of their pain (Toblin, et al., 2011). These data would indicate that the majority of people with moderate to severe persistent pain are not managing their pain with opioids. It thus seems possible that pain doesn’t inevitably lead to suffering. Indeed, when the majority of people with moderate to severe pain are not using opioids, it would seem that it is not only possible, but the norm. 

We might therefore conclude that the use of opioids despite the harm associated with them is not the only humane response to living with moderate to severe persistent pain. Indeed, it is not even the normative response. 

So what makes the use of opioids for those with persistent pain so compelling?

As described above, the notion in public policy that opioids, as a class of intervention, should be prescribed less is a highly threatening prospect for those who have managed their pain with the long-term use of opioids. Opioids are seen as their lifeline. In response to the potential reductions of opioids, their fear or anger (or both), whether it be in the clinic consulting room or in the public policy arena, is palpable and genuine. In such situations, it is easy for those who advocate a reduction in the use of opioids to begin to doubt the reasonableness of this solution to the opioid epidemic of addiction and death. In other words, it’s hard to overestimate how compelling the use of opioids is for persistent pain. Despite the aforementioned clinical and epidemiological data to the contrary, the perception that pain leads inevitably to suffering without the use of opioids can come to be readily seen as obviously true.

Let’s come at the compelling nature of opioid use from another angle.

Anyone who has had people with alcoholism in their life has had interactions in which the people with alcoholism are threatened by the prospect of becoming sober. At a certain stage of alcoholism, those who are dependent would like nothing more than to rid themselves of the problems generated by alcohol, but not rid themselves of the alcohol itself. A life without alcohol at this stage seems intolerable. Notice that this perception of threat is seen typically only from inside the eyes of the one with alcoholism. Their friends and loved ones readily see the advantages to giving up alcohol. They don’t see a life without alcohol as intolerable, but rather as a perfectly good solution to what ails the alcoholic.

This difference in perceptions between the person dependent on alcohol and those who aren’t dependent is a hallmark that we use in everyday life to determine when people have a problematic relationship to alcohol. Indeed, even professionally trained clinical providers use a variant of this characteristic when diagnosing a substance use disorder. Providers refer to this criterion as continued use despite harm. In other words, people dependent on alcohol continue to use alcohol despite the risk of problems generated by their use, because going without alcohol seems to them a worse fate than continuing to risk alcohol-induced problems. 

In this sense, dependency on a substance is in part a perception problem. Going without alcohol is perceived to be an intolerable solution to their use. It’s a perception that others, who presumably are not dependent, do not share. 

Now, here is an important point. In the case of alcoholism, others readily see past the assertions of the alcoholic and don’t believe it when the person with alcoholism reports that they just wouldn’t be able to go on without alcohol. When alcohol dependent people report that life without alcohol would be intolerable and so they will continue to drink despite the risk of death, say, from liver disease or varices, others without alcohol dependence remain unconvinced that abstinence from alcohol would be intolerable. It's clear to most of us that life without alcohol isn’t intolerable. Whatever level of distress that leads people with alcohol dependence to drink can, of course, be managed without alcohol. Indeed, it is readily acknowledged that such distress is always better managed without alcohol. 

In this discussion, we’ve used alcohol as the example because it is the substance that is likely to be the most well understood by readers. However, this characteristic of dependency can apply to other substances too. The perception of threat when considering going without, which tends to lead to continued use despite the risk of problems generated by the use itself is a hallmark of dependency to any substance. Those who are dependent tend to perceive the intolerability of abstinence, while those who are not dependent see cessation of use as the solution.

With opioid use, over the last few decades, this differentiation of perceptions has been harder to make. We don’t tend to so readily see past the expressed perceptions of those with persistent pain who use opioids on a chronic, daily basis. Indeed, when people with persistent pain taking long-term opioids assert that life would be intolerable without opioids because of pain, a large number of fellow stakeholders believe them, whether it is fellow patients, healthcare providers, or the general public. It’s easy, it seems, to perceive pain as an intolerable experience itself, which warrants extreme measures to alleviate it. 

What makes, though, opioids different from all other substances? Why do we readily recognize alcoholism or other forms of substance dependence when someone perceives cessation of use as an intolerable threat, but turn around and readily believe the long-term user of opioids when they consider cessation of use as a similarly threatening experience? We take their perceptions at face value: the perception that life without opioids would be intolerable seems an altogether believable reality of their plight in life. 

However, the fact that the majority of people with severe persistent pain in the general population do not manage their pain with opioids belies the accuracy of the perceptions of those dependent on long-term opioids. The fact that even those who have managed their pain on long-term opioids routinely taper opioids and do well once they participate in a chronic pain rehabilitation program also belies the accuracy of the perceptions of those who remain on opioids. 

Maybe at the end of the day, the compelling nature of the perceptions of threat, when people who manage their pain with long-term opioids consider a life without opioids, is really just the compelling nature of dependency on opioids. They experience the prospect of reductions and tapering as highly threatening and so are willing to continue their use despite the risk of accidental death, not because pain without opioids is inevitably intolerable, but because of the very nature of dependency itself. 

Stigma silences the discussion

Talk like this in public policy debates is fraught with consternation and fury. Those who might agree become anxious and look down, holding their tongue, while those who disagree are offended and angry. Anyone who brings the subject up is immediately met with caution from the former and accusations of ignorance by the latter: the right to say such things is immediately challenged because whoever says it cannot understand why opioids are necessary because they do not have (it is presumed) persistent pain. Different arguments subsequently arise that common conditions like chronic back pain might be manageable without opioids, but rare diseases cannot. Still further accusations emerge that talk of how dependency on opioids influences perceptions of what life is like without them is simply just another means to further stigmatize an already stigmatized population. 

In response to such fury, the observation that opioids influence the perceptions of what is possible in those who are dependent on them can quickly go nowhere. No one really wants to have the conversation. The response to discussions that attempt to take stigmatized subjects out of the closet is often to quickly and summarily put them back into the closet.

Empathy, compassion and the light of day

The observation that opioid dependency is the unspoken factor that maintains the central dilemma in the public policy debate over opioid management for persistent, benign pain is not to imply criticism or stigma, but an observation that comes from empathy and compassion. Its an observation that tells us something of what it is like to be dependent on a substance — it’s hard to imagine a tolerable life without it. Not scorn, but compassion is the appropriate response from those who are not so dependent.

In this spirit, defensive rage is met with neither stigmatizing scorn nor silence, as both responses simply serve to maintain stigma and the state of dependency. Rather, it is met with a patient empathy and a sincere attempt to connect and join with people who are so vulnerable. Patience, empathy, human connection are what’s called for, but also a gentle persistence to keep the subject of opioid dependency in the light of day, as a subject that really is okay to talk about, without judgment.

While the observation calls for all these therapeutic and humanitarian responses, it does not call for agreement with the perception that pain is inevitably intolerable without opioids. Persistent pain, even persistent severe pain, is possible to manage well without opioids. In fact, as we have seen, it is the norm. 

Rather than colluding with the dependency and subsequently recommending a continuation of prescriptions of opioids, let’s compassionately show those with persistent pain who are dependent on opioids another way, a way that involves empowerment and the taking back of control from a state of dependency to a state of well-being in which they competently and successfully are able to self-manage persistent pain.

Conclusion

It is possible to successfully self-manage severe chronic pain without opioids. People do it every day. Let’s not ever lose sight of this fact, for it is chock-full of hope. Yes, for those who are dependent, the prospect can be threatening and hard to believe. Human connection, however, can build trust. In such connection, we can show those who are dependent on opioids for the management of persistent pain a new way to manage their pain, a way that allows them to successfully and competently self-manage their pain without opioids. This prospect is truly a good thing, not a bad thing, and it requires a connection and the fostering of trust to change the perception from threatening to hopeful.

In this way, public policy should continue to maintain reductions in the use opioids for persistent pain because lives are being torn apart by addiction and people are dying of overdose at epidemic proportions. However, public policy must also be done with humanity to meet and join with those who are threatened by the prospect of life without opioids, despite the risk of opioid-related harm from addiction and death. We need to join with them where they are at, engaging in patience, empathy, compassion, and a gentle persistence to keep the subject of opioid dependency in the light of day. In so doing, we cannot simply taper opioids without doing anything more. We must take the therapeutic time, energy and cost to show them how to successfully self-manage pain without opioids. They deserve nothing less.

References

Centers for Disease Control (CDC). (2019). CDC Guideline for Prescribing Opioids for Chronic Pain. August 29, 2019.

Minnesota Department of Human Services (MN DHS). (2018). Minnesota Opioid Prescribing Guideline, First Edition. March 30, 2018.

Nahin, R. L., Sayer, B., Stussman, B. J., & Feinberg, T. M. (2019). Eighteen-year trends in the prevalence of, and heath care use for, non cancer pain in the United States: Data from the Medical Expenditure Survey. Journal of Pain, 20(7), P796-809. doi: 10.1016/j.pain.2019.01.003

Toblin, R. L., Mack, K. A., Perveen, G., & Paulozzi, L. J. (2011). A population-based survey of chronic pain and its treatment with prescription drugs. Pain, 152, 1249-1255.

U. S. Department of Health and Human Services (HHS). (2019). HHS guide for clinicians on the appropriate dosage reduction or discontinuation of long-term opioid analgesics. October, 2019.

Date of publication: February 7, 2021

Date of last modification: February 7, 2021

About the author: Dr. Murray J. McAllister is the founder and publisher at the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its 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.