A RECENT JAMA NEWS release asked whether the marketing of opioids to physicians
was associated with overdose deaths. The article pointed the finger at
both the marketing tactics of pharmaceutical companies and at the physicians
who are prescribing the medications. But the truth is, there are multiple
stakeholders, individuals and entities contributing to the opioid epidemic.
So, to cure it, we all have to play a role.
The JAMA study set out to investigate a potential association between the
opioid medications to physicians and the opioid-related death rates of the counties in which
those medications are marketed. In short, the research found that the
more marketing dollars pharmaceutical companies spent in the counties
studied, the more physicians prescribed the drugs and the higher the associated
death rates were. Though the study pointed only to correlation, not causation,
the picture it paints oversimplifies the equation. The bigger picture
can be much more complicated – for doctors and their patients, as
well as for society as a whole.
As a physician with sub-specialty expertise in the treatment of acute,
chronic pain, I know how difficult and elusive successful treatment can be. I believe
strongly in the concept of education as analgesia. In other words, the
more insight individuals have about the nature of pain signals, the anatomy
of pain pathways and the reasons for why they feel what they feel, the
better their pain management. I'm aware of the benefits of multi-disciplinary
approaches that incorporate combinations of medication, therapy, rehabilitation,
cognitive-behavioral therapy and interventional procedures (as compared
to a focus on pain pills alone). I understand that opioids have a long
history of providing very effective pain relief in certain circumstances.
But there are specific considerations that must be understood to optimize
their benefit and minimize their risk. And I understand how neuromodulation
is evolving as a state-of-the-art approach to pain management that can
minimize or eliminate the need for opioids by applying stimulation to
the brain or peripheral nerves to overcome and eliminate pain.
But just like the contributing factors to the
opioid epidemic can be oversimplified, many tend to think of pain itself in simplified
terms. Many people's concept of pain is that it's a warning sign
or signal that something is wrong, something has been injured or is at
risk for injury. This is often true of acute pain. It is a symptom. But
chronic pain is much more complicated and can be quite different. As opposed
to just a symptom, chronic pain can be considered a disease in and of
itself. The biopsychosocial model of pain tells us that there are emotional,
cultural, and other contributing factors. And neuroscience is showing
that the brains of individuals who've had early traumatic experiences
may develop to process pain signals differently and place those individuals
at increased risk of intractable pain. Add to this complexity the societal
pressures and demands for instant answers, instant results, and instant
access to an internet full of medical information and recommendations.
Clearly, treating pain is complicated. No pill, even an opioid, can be
a simple cure for
chronic pain. There may be no simple cure. It's been said that chronic pain is
less like a puzzle than a mystery. Puzzles have an "answer."
But sometimes there's no clear answer or resolution to a mystery.
The search for a chronic pain cure in a pill (or an injection, or a surgery)
is elusive. It's not that simple.
Ironically, some of the additional factors that likely contributed to the
opioid epidemic were related to the genuine desire by prescribing physicians
to be a "good doctor." At the same time pharmaceutical manufacturers
were doing their marketing, medical societies, medical authorities and
state medical boards were educating physicians on the need to address
pain in every patient. In fact, physicians were required to view pain
assessments as the "fifth vital sign," something that must be
specifically and explicitly assessed at every patient interaction. In
many states, physicians were obligated to demonstrate that they had undergone
additional continuing medical education credits in pain management in
order to renew their licenses. In addition, direct-to-consumer marketing
resulted in patients evolving to much more "aggressive" requests
from doctors to cure their pain – ("not now, but right now").
The opioid epidemic didn't occur as a result of a simple equation
of manufacturer marketing resulting in increased physician prescriptions.
It was a perfect storm with multiple variables and factors.
Curing the opioid epidemic will require a multifaceted effort by all stakeholders.
Well-intentioned efforts to point out simple correlations without taking
into account systemic factors significantly increase the risk of un-intended
consequences. For instance, in the interest of addressing the opioid epidemic,
there has been a recent focus on what many physicians feel are heavy-handed
laws and protocols meant to reduce physician prescribing. Some physicians
have simply stopped prescribing these medications all together, rather
than judiciously prescribing to the subset of patients who are appropriate
candidates, which likely results in a significant reduction in appropriate
pain management. Un-treated and under-treated pain reduces patient productivity
and quality of life – but also has physiological consequences that
may result in other dangerous medical problems. And some individuals who
cannot secure necessary pain control from their physician will resort
to illegally acquired drugs that place them at higher risk of misuse/abuse,
or consider catastrophic alternatives such as suicide. Holistic approaches
to this epidemic are needed. Cooperation between manufacturers, physicians,
patients, medical societies, medical boards, legislators and other stakeholders
is needed and necessary to appropriately address the pain of the opioid epidemic.
The vast majority of physicians went into medicine to help people. Some
patients benefit from and need
as part of responsible and appropriate pain management. And we've
got to do a better job at safely prescribing these medications for pain.
We've got to do a better job at instituting neuromodulation and multidisciplinary
approaches to pain management. We've got to spend the time necessary
to educate patients and to understand how culture and development, and
emotional or behavioral status, contribute to pain. We've got to show
patients that we do care, and that we will first, and always, do no harm.
But we need help. We need appropriate support from legislators, medical
boards, medical societies, family members, patients and other stakeholders.
We all played a role in the evolution of the epidemic. And we'll all
need to play a role in its eradication.