Conflating Pain Mgmt & Opioid Abuse

Conflating Chronic Pain Management and Opioid Abuse Potential by Charles E. Argoff, MD – April 14, 2017

Appropriate, meaningful, and compassionate treatment options for tens of millions of Americans with persistent chronic pain have come under significant scrutiny in the past few years in the face of our nation’s deepening concerns with rising opioid abuse rates.

As a physician who is American Board of Medical Specialties certified in neurology and in pain management, I focus on prescribing safe, responsible, and effective treatments for people who are experiencing severe chronic pain.

In that context, I am increasingly concerned that policymakers and prescribers are conflating two different and critically important issues. 

Addressing the treatment needs of people experiencing severe chronic pain and addressing real concerns regarding the abuse and misuse of various controlled substances, including opioids, are being conflated to such an extent that, as a result, the concept of undue harm to people in pain is becoming the new standard of care due to the sudden cessation of treatment that had previously been efficacious. This is clinically unacceptable

The foundation of the accepted standards of medical practice is based upon offering appropriate treatment in as safe and effective a manner as possible. When clinicians are able to choose among multiple treatment options for any medical condition, the safest options are meant to be prioritized over those that are less safe. This principle of medical practice is extremely relevant to pain management.

Tens of millions of people experiencing severe chronic pain do not experience sufficient relief from multiple nonopioid therapies.

I feel vindicated when I see a prominent doctor agree that nonopioid therapies are usually not sufficient. Only the CDC believes they are.

For these tens of millions of people experiencing severe chronic pain, who have not benefited from nonopioid therapies, chronic opioid therapy may be a safe and effective treatment approach.

What is the state of available opioid analgesics? Currently, multiple opioid analgesic preparations, including multiple distinct opioid chemical entities, can be prescribed.

As is true with various nonsteroidal anti-inflammatory agents, statins, and certainly with medications used to treat diabetes, while one compound may be effective for some patients, a different compound may be best for others.

This concept is at the core of personalized medicine.

The reality is that for millions of people with chronic pain, opioid therapy is effective and safe in helping them to live more comfortable and productive lives.

This is true even in the absence of abuse-deterrent formulations for all opioids and for all prescriptions, but we can and must do even better on three fronts.

First, we must maintain the availability of multiple specific opioid analgesics to meet the specific and personalized needs of the people we treat who, without such availability, would suffer unnecessarily

Second, we must take actions that meaningfully incentivize the development of the next generation of abuse-deterrent formulations.

Third, we must ensure that those experiencing severe chronic pain, for whom chronic opioid therapy is an appropriate treatment option, have access to the safest medication options currently available.

In summary, conflating appropriate and effective opioid use with opioid abuse and harm will neither help those who benefit from chronic opioid therapy to be optimally treated, nor will it sufficiently address the disease of addiction, as well as the harms associated with opioid abuse and appropriate treatment for such.

Author: Dr. Charles Argoff, and I am a professor of neurology at Albany Medical College and director of the Comprehensive Pain Management Center at Albany Medical Center in Albany, New York.

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