Tuesday, January 22, 2013

Our Hysterical Approach to Chronic Pain and Opioids

SAMHSA recently issued a report about addiction program treatment admissions where the primary problem was a combined dependence on benzodiazepine anti-anxiety and opioid pain medications. There has been a marked increase in such admissions, in the face of overall decrease admissions for other psychoactive substances (see chart below.)

Number of admissions for combined benzodiazepine and opioid dependence:

What is interesting is that the prevalence (the proportion of people in the country with a disorder) of each has not risen since 2002. Here is the annual prevalence of opioid and other illicit drug dependence or abuse according to NSDUH data. As you can see, dependence upon prescription opioids has remained stable between 2002 and 2011. What has changed is the number of people presenting for treatment, and deaths due to prescription opioids, both of which have risen dramatically in recent years. It is very likely that the increase in people seeking treatment is a result of the increase in opioid addiction that occurred between 1998 and 2002. Many, if not most opioid addicts seek treatment only after several years of addiction. Thus, there is not a new epidemic of opioid addiction. There is an increase in treatment seeking.

It is important to note the downturn in 2011. Drug epidemics typically end when drug users and, especially, potential drug users become aware of the dangers of using certain drugs, and elect to stay away from the dangerous ones. PCP was once a national scourge, as was cocaine and methamphetamine. Usually, the epidemic starts to wane about the time that there is a national hysteria whipped up about them, and lawmakers typically invoke all sorts of draconian laws amidst many lofty and moralistic statements. Thus, it appears that policies resulted in reduced drug use, but more often, the drug use was decreasing before the policies took effect. That fact, of course, is never acknowledged by the policymakers, but why would they, when their job is to get re-elected?

And just a brief note about proportionality of the problem. In spite of all the hysteria, it is important to remember that cigarette smoking kills almost 500,000 people in the US annually, and alcohol about 80,000. The number of opioid overdose deaths? Recently, the CDC reported that almost 15,000 deaths occurred from opioid overdose in 2008, a number that has almost certainly risen since then. Yes, this is a serious problem that must be addressed. But considering that cigarette smoking causes about 30 times as many deaths helps keep this in perspective.

We are currently in an era of hysteria over an increase in prescription opioid addiction which is already on the wane. Unfortunately, what we can anticipate now are ill-advised, arbitrary and draconian policies to deal with this problem. I'm not suggesting there is not problem; it is a serious one. But by approaching this with hysterical and moralistic fear-mongering and condemnation, we are going to hurt many people, especially people with chronic pain and the physicians who treat them, without necessarily doing much if any good.

Right now, there are a group of moralistic medical scolds with fervent beliefs not supported by solid empirical evidence who have the national attention. The vacuum created by the lack of evidence is filled with hot air and strong opinion, and because their moralistic pronouncements fit with most peoples' prejudices and ignorance, and this country's Calvinistic attitudes, they are accepted without appropriate skepticism. We now have a full-blown witch hunt going on that will result not in appropriate modification of treatment of chronic pain. Instead, it will increase suffering, result in preventable deaths due to opioid overdose, lack of access to appropriate opioid maintenance and mental health treatment and increased suicides among chronic pain sufferers, and destroy the professional lives of physicians who treat pain. There is a better way, but I doubt we will take it.


1 comment:

  1. I think it is interesting that the evidence based approach to chronic pain taken by NICE in the UK is basically the same approach that existed in Minnesota in the 1990s before the escalation in opioid use for chronic neuropathic pain. One could argue (and some have) that the Joint Commission pain initiative in 2000 was poorly thought out, not evidence based and led to a sudden increase in opioid prescriptions and accompanying increases in addiction. I certainly agree that tobacco related deaths overshadow deaths from opioids, but the CDC likes to point out that in many counties the deaths from accidental overdose exceed traffic deaths and that is another common sense marker of lethality. From a physician standpoint the question is - does it make sense to take that kind of risk when you look at the benefit/risk of actual pain relief accomplished versus mortality and morbidity including decreased functional capacity.