This is the second in a series on opioids & chronic pain. If you know someone with a painful chronic illness, please share this article.
Opioids chronic pain debate: cause of epidemic or proper pain relief?
In 2003, Nursing Times argued the evidence for treating “chronic non-malignant pain” with opioids (Chronic pain and opioids: dispelling myths and exploring the facts). The pendulum has swung far in the other direction since then. Now, articles frequently link opioid chronic-pain prescriptions to the “national epidemic of opioid overdose deaths and addictions” in the US.1 According to the New England Journal of Medicine, “opioid analgesics are widely diverted and improperly used.”
Since drug-related abuse and deaths have increased, many say that restricting prescriptions for opioids in non-cancer pain such as rheumatoid disease (RD) is the solution. Meanwhile Centers for Disease Control & Prevention (CDC) has published new guides stressing that opioids are not effective in chronic pain anyway.
Let’s consider two critical questions raised on opioids / chronic pain:
(1) Are opioid prescriptions responsible for the epidemic?
(2) Is chronic disease pain the same thing as chronic pain?
1. Are prescription opioids for chronic pain responsible for the opioid epidemic?
Some claim a large percentage of opioid abuse in the US is due to drugs “diverted” from legal prescriptions. However, many reports show illegal drugs transported across the US southern border are responsible for most so-called “opioid deaths.” NIH graphs seem to show that about half of opioid overdose deaths are actually heroin related. According to CDC, fewer than half of opioid deaths involve prescription opioids.2
It is hard to sort out the facts because most media reports combine statistics for illegal heroin and fentanyl and legal opioid medications. Compare the images from a National Institutes of Health (NIH) page created with CDC statistics. And according to a CNN report, “Epidemiologists in several states blame the increasing number of drug-related deaths on greater use of heroin and synthetic opioids, such as fentanyl.”
In Florida, most illicit opioid use has been linked to illegal activities of “pill mill” doctors. While the state has worked hard to shut down the operations responsible, patients have also endured new and severe medication restrictions that even leave them unable to fill legitimate prescriptions.
Yet, most who abuse opiates obtain them illegally. And there is evidence that treating chronic pain patients with opioids is associated with a very low risk of addiction.3 In a study treating veterans for pain for at least 3 months, only 2% developed opioid abuse.3
“The clinical studies referred to above indicate that opiate addicts and pain patients are largely separate populations and that opiate addiction due to appropriate medical management of pain is rare.”3 Patients who properly used opioids for pain are likely to continue doing so, as CDC reports seem to suggest. It is doubtful whether restricting access to legal medicines will have much effect on illegal drug use.Opiate addicts & pain patients are separate populations. Addiction w/pain management is rare… Click To Tweet
Opioids: chronic pain versus acute pain
2. Is chronic disease pain actually the same thing as chronic pain?
As we have discussed, there are several reasons pain from chronic diseases like RD does not actually meet definitions for “chronic pain.” The CDC says chronic pain is “pain that typically lasts >3 months or past the time of normal tissue healing.” But with active RD, various immune cells attack a joint, causing repeated damage without chance for recovery as with injury.
Pain from chronic diseases like RD is mostly acute pain that appears with disease activity. Disease activity is variable in some diseases, so pain can reappear during relapses (flares) or be longer-term if disease activity is persistent. This is an important distinction because CDC has attempted to ease public angst over its campaign for opioid restrictions by establishing that opioid pain relievers are ineffective in chronic pain.
CDC took the lead on new opioid guidelines, but FDA pursues change
In the US, it is Food and Drug Administration’s (FDA) role – not CDC – to label medicines for various “indications” (diagnoses). FDA decisions result in what consumers call “package inserts” which list indications, possible side effects, etc. Indications in inserts for medicines containing opioid pain relievers say they treat “severe pain.” However, FDA is fully cooperating with CDC’s campaign to restrict opioid pain relievers. We might expect updates to inserts that change the indication to exclude using opioids for chronic or longer-term pain.
Neither CDC nor FDA can tell people with chronic disease pain that opioid pain medicines don’t work. Many patients know for themselves that they do work. When pain is too much to bear, people with RD and other chronic diseases find opioid pain relievers effective.
Personally, my RD pain is extremely severe. It is not less severe because it is frequent or because I have every joint involved. It is not chronic pain and does not correlate with definitions of chronic pain. It is sharp and acute, reactive to specific joint movements, and the result of specific ongoing destructive disease activity in my joints.
Neither @CDCgov nor @US_FDA can tell people w/chronic disease pain meds don’t work. We know they do Click To Tweet
You might also like to read:
- Opioid Restrictions Versus Patient Needs
- Chronic Pain vs. Recurrent Acute Pain in Rheumatoid Disease
Cancer pain, chronic disease, and opioids
The elaborate CDC opioid chronic pain guidelines published in 2016 specifically separate “pain outside of cancer treatment.” Medical literature commonly differentiates between “malignant” and “non-malignant” pain. Restrictive opioid guidelines do not apply when people have cancer.
But I wonder whether the current distinctions are correct. Just as recurring pain from a chronic disease may not necessarily be “chronic pain,” so cancer pain may not always be unrelenting severe pain requiring continual opioid use. There is no contest over who has more severe pain because, as I always say, there is no prize. However people with cancer do not necessarily hurt more than people with RD.Pain from RD is very severe. Not less severe because it’s frequent or has more joints involved #rheum Click To Tweet
Originally, there was a distinction between cancer and non-cancer pain because natural time limits were more likely to exist for people with cancer than other diseases, i.e. they would likely die sooner. However, according to the American Cancer Society, cancers are often considered chronic diseases, since patients now are able to live with them for years. “So is it becoming a chronic condition like rheumatoid arthritis or insulin-dependent diabetes?” says the Stanford University blog.
This is one more area where models should be updated to correspond to current knowledge about diseases and how they are managed. It is more challenging to consider context, but it would produce more appropriate guidelines. For example post surgical pain is usually treated around the clock for a few days, but people with diseases that cause severe pain on a regular basis do not necessarily take opioids every time they have pain. Usually, they develop several strategies to deal with symptoms, and opioid pain relievers are only one part of that.
We’ll look at some of those strategies next in this opioids – chronic pain series: Are there workable opioids alternatives for pain?
This post is Part 2 in a series on opioids chronic pain. Click here to read Part 1.
Click to watch Local WESH 2 news video interview with Deb Houry from CDC defends her position on opioids & chronic pain. Some officials disagree.
- Can Bones Hurt? Bone Pain and Rheumatoid Disease
- The Role of Pain in Rheumatoid Arthritis
- What Causes Rheumatoid Arthritis Pain?
1 Volkow ND, McLellan AT. Opioid abuse in chronic pain — Misconceptions and mitigation strategies. N Engl J Med 2016 Mar 31 [cited 2017 May 28]; 374:1253-1263. doi: 10.1056/NEJMra1507771
2 CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016 [cited 2017 May 28]. Available at http://wonder.cdc.gov
3 Fields HL. The Doctor’s Dilemma: opiate analgesics and chronic pain. Neuron. 2011[cited 2017 May 28];69(4):591-594. doi:10.1016/j.neuron.2011.02.001