Current figures suggest that more than 2 million people in the United States suffer from substance use disorders related to prescription opioid pain relievers, including medications like hydrocodone and oxycodone. Addiction is very expensive in terms of both financial losses and human suffering. The total monetary cost to our society of prescription opioid abuse is estimated to be over 55 billion dollars, with close to half resulting from lost earnings and lost productivity in the workplace and another half due to excess medical costs including emergency room visits. Deaths from prescription pain reliever overdoses more than tripled from 1990 to 2010; there were 18,893 such deaths in 2014 alone.
The year 2012 saw 259 million prescriptions written for opioid painkillers; this is roughly the number of adults in the US population. These medications are almost miraculous in their ability to relieve acute pain from tissue damage due to surgery, injury, or terminal cancer. The use of these medications for chronic pain, such as low back pain and headaches, however, can lead patients to addiction and even put people at risk for heroin use. In the U.S. today, 29 million people still do not have any health insurance despite the Affordable Care Act; many who do have insurance cannot afford the copayments to keep seeing a doctor. Providers are also subject to legal limits on offering such prescriptions; in some communities, the only option available to a patient in chronic pain may be illegal and potentially dangerous substances like heroin that mimic the effects of the pain-killing opioids.
I am going to go out on a limb here and say this: I don't think many people get into abusing prescription opioids, or switching to heroin (with all its attendant risks of criminal prosecution, procurement dangers, and uncertain ingredients and dosages) just to have a good time. They risk losing their jobs, families, and social networks to their addiction, not to mention their health and peace of mind. I do think that many people have fallen down a rabbit hole of pain, and they can't get out alone, and they can't get appropriate help because it is not available to them. Serious socioeconomic inequities are at play here, of course, and these need to be addressed in our society. But here I just want to focus on one part, likely the first, in this complex and terrible cascade --pain.
"Pain is soul destroying," Marcia Angell, M.D. wrote in 1982. Having to experience pain every day can focus a person's life on that and that alone. It's difficult enough for many to keep going, working several jobs, or being unemployed, caring for children and elderly parents, dealing with economic uncertainties. Many adults in the United States try to do all that is required of them even while they are in severe chronic pain. At some point in their lives, over 80 percent of people in the U.S. population experience an episode of debilitating low back pain, and for about 5% the pain persists past three months and becomes chronic; up to 85% of those who have one bout will have a recurrence. About 16% of people in the US have chronic migraines or other severe headaches. Knee osteoarthritis, which brings substantial pain, joint stiffness, and difficulty getting around, affects millions of U.S. adults. Chronic pain is relatively common.
For many people, however, chronic pain is mismanaged, leaving them at risk for addiction. For example, opioid medications are prescribed for chronic low back pain without ever having tried other modalities (see some described below); this can begin a cascade of problems. I think it is fair to say that, generally, medicine does not fully understand chronic pain (i.e., pain that lasts for months after tissue damage has healed). People vary widely in how much chronic pain they feel. The degree to which pain limits them depends upon a host of factors, including the meaning of the pain to them, how much stress they are under, and their expectations for relief. Because the complexity of chronic pain has been in large part ignored in U.S. healthcare, I think we have gotten our approach to chronic pain all wrong. In the U.S., medical care for chronic pain tends to focus almost exclusively on trying to 'banish' it with (mostly narcotic) drugs. Writing prescriptions, however time-efficient, can end up being very costly and it does not work. Opioid medications introduce side effects and a significant risk of addiction, and can even increase a person's sensitivity to pain (a phenomenon called opioid-induced hyperalgesia).
Chronic pain is far too complicated to approach simplistically. For one thing, pain is all in the mind. Where else could it be? Our pain "signals" are always interpreted by our minds in the context of everything from our past experiences to how we are feeling about our lives at the moment. Studies show, for example, that if we expect a treatment to relieve our pain, it likely will, even if it is an inert substance like a sugar pill. Studies also show that if we are depressed or anxious or under stress, we feel more pain. This doesn't mean that our pain is not real; it means that the experience of pain is a complex process in our minds, and the relief of our pain is also.
One of the best books I have read on the role of the mind in the management of pain and other symptoms is the newly released Cure: A Journey into the Science of Mind Over Body. It is a well-written and well-researched investigation into the role of the mind in health and healing by science writer Jo Marchant, who explores how our responses to pain and other symptoms depend on our expectations and beliefs, and levels of relaxation, stress, sadness, and attention. Marchant and many others who have looked deeply into this phenomenon have concluded that if we accept the power of our minds in the interpretation of our bodily experience, we can open up a world of effective ways to be healthier.
There are many safe approaches to treating chronic pain that really work and do not use drugs at all. The National Center for Complementary and Integrative Health (part of the National Institutes of Health) today has a budget of over $100 million to support research and offer information and training on treatments such as Mindfulness Based Stress Reduction (MBSR) Meditation and Traditional Chinese Medicine (TCM) (including acupuncture and Chinese herbal formulas). These and other approaches show impressive effectiveness in managing chronic pain. There are many more avenues to chronic pain management. In his book, Watch Your Back, Dr. Richard Deyo (see 12/2014) offers convincing evidence for exercise/movement and Cognitive Behavior Therapy in treating chronic low back pain. Weight loss and exercise can help immensely in the management of chronic knee pain from osteoarthritis. Yoga is very effective in chronic pain management. In her book, Cure, Jo Marchant describes the successful use of Clinical Hypnotherapy among burn patients (who must endure treatments which inflict possibly the worst pain imaginable). Other modalities such as Chiropractic, therapeutic massage, and Active Release Therapy are used by millions. In fact, recent research shows that today in the United States, about 4 in 10 adults (and 1 in 9 children) are using some form of Complementary and Alternative Medicine (CAM). Latest statistics show that Americans pay almost 34 billion dollars per year out-of-pocket for alternative treatments because their health insurance, if they have it, offers them limited options, if any. I think it is fair to suggest that perhaps so many people are paying out so much money because these therapies help them feel better.
In 1982 Dr. Angell wrote: "No patient should have to endure pain unnecessarily....Few things a doctor does are more important than relieving pain." The epidemics of opioid abuse and chronic pain need to be addressed with better management that includes harnessing the mental and behavioral abilities of patients to eliminate or reduce their pain. Physicians in training and in current practice need a commitment to, and in-depth training in, the effective management of chronic pain using multimodal approaches. If opioid medications do make sense for a particular patient with chronic pain, their use must be part of an overall strategy including behavioral change (weight loss, exercise, movement), as well as approaches such as TCM, yoga, meditation, and the identification and management of anxiety, stress, and/or depression (all of which make pain even worse). We need to go well beyond a reliance on powerful pain-relieving medications. We need to develop better approaches to caring for the whole person who is in pain.