Managing Chronic Pain in the Wake of the Opioid Backlash
In the United States, more than 25 million adults (11%) report daily (chronic) pain and nearly 23 million adults (10%) report a lot of pain. Low-back pain is the leading cause of years lived with disability both in the U.S. and globally, and accounts for one-third of all work loss. Regrettably, National Institutes of Health (NIH) funding for pain research declined sharply from 2003 to 2007 – by an average of 9% per year – and the federal response to an Institute of Medicine report on pain ("Relieving Pain in America," 2011) has been limited and disproportionately focused on reducing opioid use rather than increasing pain relief. This JAMA Viewpoint commentary discusses several options for managing pain, as well as the overuse of the term "opioid epidemic."
Analgesic options for patients with chronic pain have steadily declined. Acetaminophen has been found to have minimal efficacy for low-back pain and only small benefit for osteoarthritis. Similarly, the analgesic effects of nonsteroidal anti-inflammatory drugs (NSAIDs) for low-back pain are very small. Tricyclic antidepressants and muscle relaxants are often used as adjunctive pain treatments, but have a relatively weak evidence base for chronic pain. Several decades ago, advocates for better pain management encouraged greater use of opioids for the treatment of patients with non-cancer chronic pain. Consequently, the number of opioid prescriptions, deaths related to opioid overdose, and opioid misuse escalated. Nevertheless, the movement to virtually eliminate opioids as an option for chronic pain refractory to other treatments is an over-reaction. Many patients currently receiving long-term opioids were started when opioids were still considered a viable treatment option, and if satisfied with their pain control and using their medications appropriately should not be unilaterally compelled to wean off opioids. Recent NIH and CDC guidelines also recognize that judicious prescribing and monitoring of opioids is a viable option for selected patients. In addition, placebo-controlled trials have shown a modest analgesic effect of opioids. Thus, the authors believe that excessive use of phrases such as "opioid epidemic" should be avoided. There is an emerging advocacy movement for the greater use of marijuana for chronic pain; however clinicians must be careful of replacing the opioid epidemic with a marijuana epidemic. Non-pharmacological pain therapies provide a promising alternative, including cognitive behavioral therapy, which has the strongest evidence base for pain relief. Evidence also exists for yoga, mindfulness or meditation-based therapies, acupuncture, and massage.
The authors warn that imperfect treatments do not justify therapeutic distrust, and suggest that there is a broad menu of partially effective treatment options that can maximize the chances of achieving at least partial amelioration of patients' chronic pain.
Dr. Kroenke is part of HSR&D's Center for Health Information and Communication (CHIC) in Indianapolis, IN.
Kroenke K and Cheville A. Viewpoint: Management of Chronic Pain in the Aftermath of the Opioid Backlash. JAMA. June 20, 2017;317(23):2365-2366.