In chronic pain management, we thus have two types of pain clinic, which see the same kinds of patients, but with almost the exact opposite treatment. It’s a remarkable state of affairs.
What’s even more remarkable is that chronic opioid management clinics flourish while interdisciplinary chronic pain rehabilitation programs struggle to survive despite the latter type of clinic being significantly more effective than the former.1, 2 Consensus based guidelines, such as what the American Pain Society developed for chronic low back pain, recommend that patients pursue a chronic pain rehabilitation program prior to engaging in chronic opioid management, because chronic pain rehabilitation programs have significantly better outcomes and higher quality evidence supporting them.3 The American Academy of Pain Medicine recently came out with a position paper calling chronic pain rehabilitation programs the ‘gold standard’ for chronic pain management.4
So, why do interdisciplinary chronic pain rehabilitation programs struggle to survive?
Chronic opioid management clinics & chronic pain rehabilitation programs
While likely involving many reasons (e.g., poorer insurance reimbursement for chronic pain rehabilitation programs), one reason is surely the widespread belief that managing chronic pain well is impossible without opioids. Indeed, it’s a commonplace to think that without opioids, patients with chronic pain will suffer. This belief leads to frequent exhortations that the only humane response to people with chronic pain is to provide them with chronic opioid management. As such, healthcare providers tend to refer, and patients tend to self-refer, to what seems like the only possible and humane treatment – chronic opioid management – and the clinics that provide it.
But, is the belief that it’s impossible to manage pain well without opioids really true? Do people with chronic pain invariably suffer if they do not have access to opioids?
Managing chronic pain without opioids
Patients and healthcare providers alike are often surprised to learn that the majority of people with chronic pain do not manage their pain with opioids. Various epidemiological studies show that, among those with chronic pain, a minority uses opioids to manage their pain. In a US-based epidemiological study conducted in 2000-2001, early into the advent of the widespread use of chronic opioid management, Hudson, et al.,5 found that, among people who had moderate to severe chronic pain, 5.78% were engaging in chronic opioid management for their pain. In a later study conducted in 2007, Toblin, et al.,6 found that about a quarter of the population had chronic pain, but only 15% of them used opioid medications to manage their pain. In Europe, the percentages range from a little less to a little more, depending on the country. However, no country reveals that most people with chronic pain manage take opioids on a chronic basis.7 Fredheim, et al.,8 for instance, in a Norwegian sample, found that a large majority of people with self-rated moderate to severe chronic pain do not manage their pain with even occasional use of opioids.
As epidemiological studies, these figures capture all people with chronic pain, whether they are actively seeking care or not. Among people seeking care for their chronic pain, the rate of opioid use increases, but they are still a minority in terms of their percentages.9 For example, in a study of worker’s compensation cases that involve seeking care for chronic low back pain, 16% of the patients obtained chronic use of opioid medications.10 We know that the people with chronic pain who manage their pain without opioids are not suffering because the majority of them are satisfied with how they are managing their pain.6 Even among people who are readily offered chronic opioid management for their pain, the majority of them will opt out of it despite their pain remaining chronic.11
Maybe it’s time to stop believing that it's impossible to manage chronic pain well without opioids. Maybe too, it’s time to recognize that it isn't unethical or inhumane to refrain from engaging in chronic opioid management when managing a patient with chronic pain. Indeed, the most ethical and humane thing to do is to provide the treatment that is most effective at reducing pain and improving functioning. That treatment, as all the guidelines tell us, is a chronic pain rehabilitation program, not chronic opioid management.
1. Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain.The Clinical Journal of Pain, 18, 355-365.
2. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain.Journal of Pain, 7, 779-793.
3. Chou, R., Amir, Q., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478-491.
4. American Academy of Pain Medicine. (2014). Minimum insurance benefits for patients with chronic pain: A position statement from the American Academy of Pain Medicine. Retrieved from http://www.painmed.org/files/minimum-insurance-benefits-for-patients-with-chronic-pain.pdf
5. Hudson, T., J., Edlund, M. J., Stefflick, D. E., Tripathi, S. P., & Sullivan, M. D. (2008). Epidemiology of regular prescribed opioid use: Results from a national, population-based study. Journal of Pain Symptom Management, 36(8), 280-288. doi: 10.1016/j.jpainsymman.2007.10.003
6. 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.
7. Breivek, H., Collett, B., Ventafridda, V., Cohen R., & Gallacher, D. (2006). Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain, 10, 287-333.
8. Fredheim, O. M., Mahic, M. Skurtveit, S., Romundstad, P. & Borchgrevink P. C. (In press).Chronic pain and use of opioids: A population-based pharmacoepidemiological study from the Norwegian prescription database and Nord-Trondelag health study. Pain. doi: 10.1016/j.pain.2014.03.009
9. Okie, S. (2010). A flood of opioids, a rising tide of deaths. New England Journal of Medicine, 363(21), 1981-1985.
10. Franklin, G. M., Rahman, E. A., Turner, J. A., Daniell, W. E., & Fulton-Keho, D. (2009). Opioid use for chronic low back pain: A prospective, population-based study among injured workers in Washington state, 2002-2005. Clinical Journal of Pain, 25(9), 743-751. doi: 10.1097/AJP0b013e3181b01710
11. Gustavsson, A., Bjorkman, J., Ljungcrantz, C., Rhodin, A., Rivano-Fischer, M., Sjolund, K.-F., & Mannheimer, C. (2012). Pharmaceutical treatment patterns for patients with a diagnosis related to chronic pain initiating a slow-release strong opioid treatment in Sweden. Pain, 153, 2325-2331.