Pain Patient Perceptions of Long-Term Opioid Therapy

Survey Elucidates Chronic Pain Patient, Household Member Perceptions of Long-Term Opioid Therapy – Pain Medicine News – July 2017 – by David C. Holzman

The vast majority of patients on long-term opioids who began therapy after surgery, an accident or an injury believe that the drugs reduce their pain at least somewhat.

And more than half said they do so very effectively, according to a joint survey by the Kaiser Family Foundation and The Washington Post

Furthermore, 

  • 57% said their quality of life is better than it would have been without opioids, but
  • 24% said it’s worse

This makes no sense: If their quality of life is worse when taking opioids, why are they taking them? 

Perhaps they are conflating their opioid use with the reasons for taking them and interpret the question as how having to take opioids for pain is worse than not having the level of pain that requires opioid treatment.

I cannot imagine anyone saying that living with their uncontrolled pain allows for a better quality of life than medicating their pain. Please let me know if I’m missing something here.

Two-thirds of patients said they were concerned that efforts to crack down on abuse of painkillers could interfere with their access to the medications.

“The sobering aspects of [the survey] are that not all opioid prescriptions are unnecessary and not all opioid receivers are drug abusers,” said Laxmaiah Manchikanti, MD, chairman of the board and CEO of the American Society of Interventional Pain Physicians.

This is one of the most reasonable statements I’ve seen, but our system is not designed to deal with a two-sided issue like this.

Instead of a clear division between good/bad, white/black, opioids are”sometimes good/sometimes bad”, mostly white (taken for pain) with <10% black stripes (abused).

contrasting these findings with the bad publicity generated by overuse and abuse of this class of drugs in recent years.

The survey covered the views of long-term users of opioids and household members of such patients on a wide variety of issues of concern to them and their physicians.

The survey’s primary goal was to shed light on users’ experience, said Bianca DiJulio, MHS, associate director of Public Opinion and Survey Research at the Kaiser Foundation.

“This survey provides a better picture of opioid use than many of the guidelines prepared thus far, which have had mostly negative recommendations, and scientific studies that looked at only short-term therapy, specifically with long-acting opioids in high doses,” Dr. Manchikanti said.

The telephone survey used random dialing to reach 809 people, including 622 pain patients and 187 members of households that included pain patients. The survey avoided including pain patients and household members from the same household.

Context

In a review last year in The New England Journal of Medicine, Nora D. Volkow, MD, head of the National Institute on Drug Abuse, and A. Thomas McLellan, PhD, wrote that

“more than a third (37%) of the 44,000 drug-overdose deaths that were reported in 2013 … were attributable to pharmaceutical opioids. …

There has been a parallel increase in the rate of opioid addiction, affecting approximately 2.5 million adults in 2014.”

And “the major source of diverted opioids is physician prescriptions” (N Engl J Med 2016;374:1253-1263).

However, Dr. Manchikanti noted a change in the last couple of years.

Prescriptions for opioids are down 25%, whereas deaths increased 2.6% in 2015.

“But the most explosive increases, ignored by authorities as well as the media,” he said, are that heroin deaths were up 15.6% from 2014 to 2015, and deaths from synthetic opioids were up 72.2% during the same period.

It’s amazing how the media was able to find scores of people suffering from a loved one’s opioid overdose, but can’t seem to figure out that “opioid overdose” doesn’t mean “pain pill” anymore, but rather heroin/fentanyl/et.al.

Results

A majority of long-term opioid users surveyed are “complex” patients.

Seventy percent (70%) reported having “significant health issues such as a debilitating disability or chronic disease, … only fair or poor physical health (42%), or taking four or more prescription drugs (57%).”

Nonetheless, more than half of patients surveyed said prescription painkillers have improved their quality of life (57%), but 16% said it has worsened.

Sixty-seven (67%) percent said efforts to address opioid abuse and overdosing have hindered their access to prescription painkillers.

Nearly all long-term users said they commenced drug treatment for medical reasons, including chronic pain (44%) and pain after surgery (25%) or an accident/injury (25%). Just 3% said they began their long-term use “for recreational reasons.

While they give numbers for almost all survey responses, they hide the number of the “nearly all” who started for medical reasons. In a fact-based article on a science-based website, this cannot be anything but deliberate concealment.

Nonetheless, although

“nearly all” users surveyed said they take opioids for pain relief,

20% also said they take opioids “for fun or to get high.”

Another 14% and 10%, respectively, reported that they used opioids “to deal with day-to-day stress” or “to relax or relieve tension.” (Some responded affirmatively to both questions.[which makes the total rate of “asbuse” less than the sum of both -zyp])

It seems like the total questionable medical use could include all of the lower percentage folks, making the total rate of “abuse” maybe 15%, not additive and 25%.

Dr. Manchikanti critiqued the survey for presenting the latter information in a way that could be misconstrued as misuse of opioids.

This is our greatest problem with the media: everything relating to opioids is presented as problematic, if not deadly, as Dr. Kolodny would have us believe.

Day-to-day stress and tension are part of chronic pain,” he said. “Consequently, these are relieved when pain is relieved.”

As for the 20% taking opioids for fun or to get high, “that’s a problem,” Dr. Webster said.

“The challenge is to identify who they are and to limit access.” But he noted that if only 20% are abusing opioids, then 80% are using them properly.

Conflation of Addiction and Dependence

Another major finding was that 34% of patients “say they think they are or were addicted or physically dependent on [opioids],” according to the report.

The report’s failure to distinguish between these two conditions was a major shortcoming, Dr. Webster said.

The problem of failure to distinguish between addiction and dependence is compounded by the fact that while dependence is common, true addiction—which Dr. Webster defined as a need for relief of mental rather than physical pain—is rare.

Typically, in any population only 12% to 18% are susceptible to addiction, but
opioid susceptibility is much lower

the differences between dependence and addiction are not clear even to many physicians outside the field of pain medicine, Dr. Webster adde

Asked about having lumped the two conditions in the survey, Ms. DiJulio implied that there were limits to the quantity of information that could be obtained within its scope. “We were not attempting to get into clinical definitions,” as this would have required much more thorough questioning, she said

Initial Conversations With Physicians

Another finding was that at the time of initial opioid prescription, just 33% of all patients had conversations with their physicians about ultimately terminating the medication.

That may not be as bad as it sounds, Dr. Webster explained, pointing out that “the vast majority” of patients on opioids for chronic pain are likely to need pain relief for the remainder of their lives.

Opioids don’t cure anything; they are just supposed to help with the quality of life,” he said.

To me this is not only obvious but also the crux of the problem: there is no cure for chronic pain. “Acute pain” will eventually heal by definition, but “chronic pain” implies it’s permanent.

Unfortunately, it seems most doctors are treating chronic pain as though it were an injury that will eventually heal (just like we ourselves did until it became clear to us that there would be no cure).

More than two-thirds of patients reported discussions of other important issues at that time, including

  • 78% on avoiding alcohol and certain medications,
  • 70% on possible side effects,
  • 68% on keeping the medications in a safe place to prevent access and misuse by others,
  • the possibility of addiction or dependence (65%), and
  • nonpharmacologic ways to manage pain.

One in five patients (20%) said they believed their physician failed to provide sufficient information on the risk for addiction and side effects, Ms. DiJulio said.

What does it mean to mention the “risk for addiction AND side effects” when addiction IS a side effect?

Same 20% using it recreationally?

Household members were far more likely than patients to report concerns about a patient’s use of opioids.

For example, 54% of household members said the patient was addicted versus only 34% of patients.

Painkillers had harmed the user’s financial situation, according to 37% of household members, versus 17% of patients.

Personal relationships had suffered, according to 34% of household members, versus 16% of users, while

physical and mental health had worsened (39% vs. 20%, and 39% vs. 19%, respectively). 

Fourteen percent  (14%) of users versus 27% of household members reported that the patient’s job performance had declined.

More than half of both groups said the patient’s quality of life had improved, Ms. DiJulio said.

Regarding physical and mental health, Dr. Webster said household members likely view the patient’s condition through a distorted lens.

“It’s difficult to separate the impact of opioids from the impact of the pain pathology,” he said.

Just like all the studies and articles,
users are conflating their opioid use
with the reasons for taking them

“So without the opioid, what would be the quality of life and the functional ability of the individual? We know that untreated and undertreated pain leads to depression, and even suicide.”

The survey really suggested that most patients have found opioids to be beneficial, and that’s contrary to what we normally hear in the media,” said Dr. Webster, adding that this is exactly what pain physicians hear from their patients.

“And I think it’s important to listen to our patients.”

Hooray, Dr. Webster, for pointing out the truth behind all these studies and ending with a reminder that doctors are supposed to be making us feel physically better.

He sees that people are upset about the amount of opioid medication we’re taking, while they remain blind to the amount of pain we’re experiencing that require us to take such doses.

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