Alternatives to Long-Term Opioid Use for Chronic Pain

In the second of a two-part series, Join Together speaks with Barry Meier, New York Times reporter and author of the new e-book, “A World of Hurt: Fixing Pain Medicine’s Biggest Mistake,” about the alternatives to long-term opioid use for treating pain.

What is and isn’t known about long-term use of opioids?

Barry Meier: One would expect that 15 years after powerful opioids began to be regularly used to treat chronic pain that this would be a relatively easy question to answer. Unfortunately, it is not, a fact that reflects both the difficulty in running clinical trials involving these drugs and the reality of what happens when medical practice runs ahead of science.

One of the principal characters in A World of Hurt is Dr. Jane Ballantyne, who was among the first pain specialists to raise a red flag about the long-term use of opioids. In 2003, Ballantyne, who was then working at Massachusetts General, started to get concerned about how patients were reacting to the drugs. She did some research and published a paper in The New England Journal of Medicine warning about serious side effects from the drugs, particularly when they were taken at high doses. She was largely ignored, but since then a number of studies have pointed to a wide range of side-effects from long-term opioid use.

How effective are opioids in treatment of long-term pain?

Barry Meier: Effectiveness in pain treatment is usually measured in two factors, reduction in pain and an improvement in physical function (i.e.; a patient can do more physically). And opioids can be very effective in the treatment of chronic pain.

But the big question – and it is a really big one – is how many patients benefit from long-term opioid use. The question exists because there is a dearth of data on long-term outcomes. However, several experts that I have interviewed put the number of patients who benefit at about 30 percent. The big problem is that another large group of patients – some studies put the number as high as 20 percent – may start abusing the drugs or develop other serious side effects.

What are the consequences for patients of long-term opioid use?

Barry Meier: Experts believe that patients fare best when opioids are used at low or moderate doses and when patients are monitored closely to make sure they are still benefiting from the drugs in terms of pain relief and physical function.

If a patient is not managed well there can serious consequences. And such problems often occur because well-meaning doctors, eager to make patients more comfortable, repeatedly increase a drug’s dose, inadvertently increasing risk. Several studies, for example, have shown a direct link between dose and overdose risk. And while fatal overdoses have dominated the public discussion about these drugs, their use, particularly at high doses, can have other significant health consequences as well. Studies have linked the drugs to severe psychological dependency, decreased hormone production, severe lethargy, sleep apnea and falls and fractures in the elderly. As dose increases, pain patients also become susceptible to a condition known as hyperalgesia, in which they feel more, not less pain.

What is the effect of long-term opioid use on worker disability rates?

Barry Meier: It appears to be pretty startling. A 2008 study by the California Workers Compensation Institute found that workers who received high doses of opioid painkillers to treat problems like back injuries stayed out of work three times longer than those with similar injuries who took lower doses. One insurer found that when medical care and disability payments are combined, the cost of a workplace injury is nine times higher when a strong narcotic like OxyContin is used than when a narcotic is not used.

Such findings are shaking up views of opioids because their use was driven by the belief that the drugs, by reducing pain, would help patients become physically active more quickly. However, such studies and others suggest that high opioid doses do not promote improved physical function and may impede it.

Is there a movement back toward a multidisciplinary approach to treating chronic pain? What could the advantages of this approach be?

Barry Meier: One of the reasons that I wrote A World of Hurt was to try to help stimulate a public discussion about alternatives to opioids. It was not to bash these drugs because they do play a valuable role. But the experience of the past decade has proven two things: The first is that opioids are not the cure-all that drug companies and their advocates claimed. The second thing is that patients, the public and doctors need to expand the conversation about pain treatment beyond how the drug industry has sought to define it.

In recent years, major studies involving the “multidisciplinary” approach were conducted by the Mayo Clinic (http://1.usa.gov/12bWYX3) and by the Veterans Administration (http://1.usa.gov/19TV4UJ). Both studies found that patients who were weaned off opioids and underwent such programs (which are now outpatient rather than inpatient) achieve significant gains both in pain reduction and in physical function.

Such programs also are not cure-all because they may not work for all patients. But these results suggest that non-pharmaceutical approaches to chronic pain can play a critical role. Also, while the programs do cost more in the short-run, their benefits both in terms of long-term savings and reductions in other opioid-related costs and problems such as abuse and addiction could prove enormous. Recently, I wrote an article in The New York Times that looked at this issue found here.

Barry Meier, a reporter for The New York Times, writes about the intersection of business, medicine and the public’s health. Mr. Meier is the author of an e-book, “A World of Hurt: Fixing Pain Medicine’s Biggest Mistake” (The New York Times, 2013), and Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death (Rodale, 2003), recently made available as an e-book. Visit his website at www.barrymeier.com.

Read Part 1 of his interview here.