An old friend contacted me last night, pleading for some advice for a condition that has left him with persistent pain. After a bit of a chat, he explained that he had been on varying doses of opioids for the past 4.5 years continuously. Having asked him what he believes to be the cause of his pain, he said,
“All my pain is apparently imaginary. My body produces too many cytokines and other inflammatories and so my brain thinks I've been doing scrimmage work with the NZ Warriors.”
He had lost hope.
“It leaves me with no one willing to address any of the residual issues, namely pain… My GP, bless him, has no fucking clue what to do now.”
Having prodded a bit more on his understanding of his pain it was clear no one had even provided him with an elementary level of pain education to allow him to have some control and efficacy in moving forward. This is not an attack on GP’s, rather the highlighting of a problem across healthcare.
In an article in The Age newspaper today, they reported, “More than 85,000 Australians are abusing pregabalin.” It made me question, are individuals abusing it, or is there a bigger issue in prescription and the understanding of pain? Perhaps some abuse occurs, but I’m not convinced that the blaming of the person in pain is the right way forward in understanding this epidemic.
From here out, I’d like to discuss the evidence suggesting we need to do better and provide more efficient pain education for both clinicians of all types, the patient, and society. The focus of this is specific to opioid prescription, but alas, this problem spans across many other common treatments.
Interestingly, there is very little evidence for the long-term use of opioids, and that is a generous sentence to say the least! The Centre for Disease Control (CDC) guidelines state,
“Clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids, often 3 days or less, unless circumstances clearly warrant additional opioid therapy. More than 7 days will rarely be needed.” (Dowell, 2016).
The CDC guidelines fact sheet can be viewed HERE.
Between the years of 1992 and 2012, there was a 15-fold increase in opioid prescription in Australia, with a consequential 32-fold increase in financial burden ($8.5 million to $271 million) on the Australian Government (Blanch, 2014). This may, in part, be due to the ageing population of Australia (Roxburgh et al. 2011), but otherwise the dramatic increase in prescription rates doesn’t seem to be evidenced.
An increase in pro-inflammatory cytokines is likely to occur with prolonged opioid use with other neuronal adaptations resulting in opioid induced hyperalgesia i.e. prolonged opioid use can increase sensitivity paradoxically doing the opposite of their objective (Hutchinson et al. 2008, Lee et al. 2011). Cyril Rivat et al. wrote a nice paper that delves into the science behind opioid mechanisms and adaptations resulting in hyperalgesia, if you’d like to explore this in more detail (Cyril et al. 2016).
The misunderstanding of pain is cause for concern. This misunderstanding is evidenced by the lack of efficacious treatments being prescribed, and the over prescription of potentially iatrogenic treatments. This is not limited to just opioid prescription – but that’s for another discussion.
A position statement in the European Journal of Pain that discusses the benefits of opioids but argues the need for better training and understanding can be found here (O’Brien et al. 2016).
The POINT study concluded similar findings (Campbell et al. 2015):
“Education and training of primary care physicians in chronic non-cancer pain and addiction medicine is crucial; the risks of high-dose consumption of pharmaceutical opioids need to be weighed against clinical evidence that patients are deriving net benefit from their use. It is crucial for primary care physicians to routinely collect detailed histories of their patients in order to determine the most appropriate treatment plan, and to consider involving specialist mental health, addiction or other services when appropriate and available.”
This most recent systematic review (Tucker et al. 2019) not only challenges the efficacy of opioids but that we also need to improve the quality of the research in this area with the current studies, specific to LBP, meeting their inclusion criteria, having a high risk of bias.
The systematic review concludes,
“We feel that one should use caution before administering opioids for the management of subacute or chronic LBP. Higher incidences of harms are present with the use of opioids and pain outcomes do not appear to be superior to comparators such as non-steroidal anti-inflammatory agents.”
In my opinion, this is where the understanding of pain has huge efficacy. Not for analgesia directly, but for better understanding of the management of pain, engagement in high value and evidenced based treatments, while mitigating risks of harm, and to empower the person seeking help to once again have control.
What do you think has to change for a comprehensive biopsychosocial approach to become the norm in first line pain management?
One organisation that is doing a great job in addressing pain education is the pain revolution. Please check out their website and donate to a great cause. Click HERE to learn more.