Over the last few years, I have argued that we need to rethink the nature of opioid use disorder in the population of people who take opioids as prescribed for moderate-to-severe persistent pain. I’ve done so in various formats, including in presentations as well as here at the Institute for Chronic Pain, in both web pages (Should the Definition of Opioid Addiction Change? and Opioid Dependency & the Intolerability of Pain) and blog posts (The Central Dilemma in the Opioid Management Debate and Dreaded or Embraced? Opioid Tapering in Chronic Pain Management). 

I do so because I think that the fields of both pain management and addiction are overly focused on loss of control as the primary indicator of when a person on long-term opioids for pain management crosses the line into the problematic state of an opioid use disorder (OUD). The argument these fields tend to use goes something like the following: 

The Institute for Chronic Pain (ICP) recently published a content piece on the roles that shame play in the experience of pain, particularly in persistent pain. It’s an under-reported topic in the field of pain management. In fact, we don’t tend to talk about it at all.

Every year, a “dead zone” appears in the Gulf of Mexico due to a gigantically large algae bloom. This summer, the National Oceanic and Atmospheric Administration predicted the dead zone to be the size of both Delaware and Connecticut combined.

The origins of the dead zone are traceable to over a thousand miles away from the farms of the upper Midwest, and all points further south. The origin, in other words, is farm run-off of nutrients from manure and chemical fertilizers. 

Farmers in these states have animals that produce manure. They also use fertilizers on their fields. With time and rainfall, nutrients from these sources seep into the Mississippi and any of its countless tributaries. Making their way eventually to the Gulf of Mexico, these nutrients in the manure and fertilizers combine with the heat of the Gulf to spawn catastrophically large algal blooms that kill everything in its wake.

Well-meaning farmers of the Dakotas, say, or Minnesota, or Wisconsin, may never know of the distant consequences of their actions. As such, it’s nearly impossible, and perhaps even unfair, to hold any one person responsible. How would you ever know, for instance, that this farmer’s fertilizer applications, as opposed to that farmer’s application, led in part to the dead zone that occurs so far downstream in space and time? In general, we can rightly say that farm manure and the application of chemical fertilizer and its subsequent nutrient-rich run-off cause of the dead zone in the Gulf, but for any one particular farmer it is much harder to make a causal attribution. 

The Gulf of Mexico dead zone, along with its distant causes, is a perfect analogy to the use of prescription opioids and the resultant opioid epidemic of addiction and overdose. 

It is often helpful to use analogies and metaphors when explaining complex health topics to patients and their families. This statement is no less true when explaining the complexities of successful pain management. There are many helpful metaphors and analogies, and we have discussed a number of them previously in this blog, such as in the different ways to relate to pain or even experience pain. Another helpful analogy to explain the nature and goals of successful pain management is with the analogy to successful weight management.

It is helpful to liken pain management to weight management because weight management is often better understood by patients and their families. So, let’s review and learn about what it takes to successfully self-manage pain by looking at how it’s similar to successful weight management.

Often in discussions of chronic pain and its treatments, self-management gets neglected as a viable option. It gets forgotten about. Or perhaps it just never comes to mind when patients or providers talk about the ways to successfully manage pain. Instead, stakeholders in the field tend to focus on the use of medications or interventional procedures or surgeries.

“Why do you guys always want to know how much stress I have?” While the patient who asked this question the other day had fibromyalgia, she could have had chronic low back or neck pain, chronic daily headaches, complex regional pain syndrome, or any other chronic pain condition. She was expressing a sentiment that I often hear in one form or another.

One of the more common sentiments that chronic pain patients express is that that the profit-motive seems to have had too much of an influence on the recommendations that their healthcare providers have made over the years. After reflecting on all the years of chronic pain and all the years of failed treatments, many of which were tried again and again despite having failed to reduce pain at previous clinics, they conclude that the business side of healthcare has played too much of a role in their own care. They are now disappointed, angry, and distrustful of chronic pain management providers.

Pain management is a catchall phrase used to describe multiple types of healthcare services for pain. Pain management can include the following types of services: