Addressing the dual crises of pain and opioids

Addressing the dual crises of pain and opioids — a case for patient-centeredness – by Beth Darnall – Oct 2018

Caring for pain has become deeply intertwined with the opioid crisis. Though largely fueled by illicit opioid use, the opioid crisis has understandably spurred national and local organizations, as well as the public, to seek methods of pain treatment that carry the lowest risks. That in turn has led to policies that often emphasize limits on opioid prescribing.

We must remember, however, that opioid limits alone do not constitute a pain care plan, nor do blanket opioid limits appreciate the individual differences across patients who live with pain.

I couldn’t agree more. Those entities passing down these opioid limits are not medical professionals, but rather bureaucrats and politicians who have no idea about the medical realities of those of us living with constant pain. Their ignorance has terrible consequences: it’s warping medical treatments and spreading the lie that “opioids lead to addiction”.

Over the past 15 years, the absence of patient-centered pain care contributed to an over-focus on prescribing opioids.

Now, we are in danger of repeating the mistakes of the past by applying a one-size-fits-all regulatory “solution” that fails to address the specific needs of the individual and fails to treat their pain.

To be truly effective, our pain treatment programs and our policies should be evidence-based.

Unfortunately, these days all studies on opioids blame these medications for the systemic destructive effects of pain itself, so there has been little evidence generated to do anything usefu with opioids. See Opioids Blamed for Side-Effects of Chronic Pain.

They should be patient-centered. And, as one component of patient-centeredness, they should be accessible to those who need them

Research is the path to evidence-based care and legislative solutions.

In a major step forward, earlier this year Congress approved billions in funding for the National Institutes of Health’s (NIH) HEAL Initiative, a trans-agency medical research effort focused on developing and investigating new and low-risk ways to treat pain, in addition to addressing opioid use disorder.

Then they should study how successfully opioids treat *real* pain patients’ pain, not some artificially created prolonged acute pain in mice.

The Patient-Centered Outcomes Research Institute (PCORI) has invested millions in funding studies to determine which pain care therapies work best for different individuals, which strategies to prevent opioid use disorders are most effective and how best to deliver medication-assisted treatment to those with addiction

The research that informs our policies and practices should reflect the realities of diverse patients and everyday situations.

That may sound obvious, but traditional research has typically included carefully selected patients. Fortunately, research funders such as PCORI and NIH are supporting the inclusion of more typical, “real-world” patients in research so that the results will be more broadly applicable.

This is an encouraging trend. Perhaps scientists are starting to realize that my above described studies with mice don’t apply in the real world, and that experimentally created pain for studies does not even approximate chronic pain in the real world.

For instance, my team is conducting a PCORI-funded study on prescription opioid tapering that has few criteria that would exclude people with pain from participating. We are testing the comparative effectiveness of two common, evidence-based treatments to help manage pain during voluntary opioid reduction.

People living with pain helped to design the study and are guiding its implementation.

Our national patient advisory board, comprised diverse representation across race, ethnicity and geographic location, is also guiding the research team. With this kind of inclusive approach, we expect that our findings will apply more broadly to patients in communities around the U.S., thereby increasing adoption of our methods and patient access to care that is acceptable to them.

As research and treatment become more patient-centered, our pain treatments will become more effective because they will be responsive to individual patients’ needs and circumstances. Pain care in the U.S. will be transformed when we focus on the right treatment, for the right patient, within a system that includes patients as true, valued partners.

This is an effort I support. It’s an indication that researchers are starting to wake up to the reality of real people living with real chronic pain in the real world.

Author: Beth Darnall, PhD is a clinical professor at Stanford University School of Medicine, Department of Anesthesiology and Perioperative Medicine and is an NIH and PCORI-funded principal investigator of chronic pain treatment and patient-centered opioid reduction research. She has authored three books for patients and clinicians on behavioral medicine for chronic pain. Follow her on Twitter: @bethdarnall.

I’m so grateful that Dr. Darnall is on our side now. She’s certainly “making amends” for how she convinced the public that most of our pain was just catastrophizing.

She’s a smart lady and should have known how her ideas would be misinterpreted by the vast “general public”, which has no patience for nuance and is marinated in anti-opioid media-hype.

Most people, even medical professionals that should know better, reached the sloppy conclusion that pain is “all in our heads” and twisted Dr. Darnall’s ideas about “catastrophizing” into blaming patients for their own pain.