On October 31, 2000, Congress passed and President Clinton signed a bill providing for the “Decade of Pain Control and Research,” which began January 1, 2001. With this designation, it was hoped that public and clinical attention and funding for research would be focused on the serious and under-recognized public health crisis of chronic pain. Although now long in the rearview mirror, the legislation served as a focal point for evaluation of progress made on this front, including, at last year’s PAINWeek National Conference, by senior faculty member Steven D. Passik, PhD, in a Special Interest Session entitled “The Iceberg Cometh.” Following his presentation, we sat down with Dr. Passik to discuss some of the lessons learned during and following the Decade of Pain Control and Research and implications for the appropriate engagement of opioid therapy in chronic noncancer pain management.
The oscillating pendulum of opinion on the advisability of long-term opioid therapy is not a new phenomenon. As part of the movement to treat pain more aggressively, the trend had been toward a liberation of opioids; to eradicating pain with insufficient regard for misuse. Today, in the view of Dr. Passik, the movement has been to return to the 1940s, when even terminally ill cancer patients were thought to be susceptible to addiction. But the key concept, Passik asserts, is that it takes the drug in a vulnerable person at a vulnerable time to create a person who abuses, not the drug itself. Our recent responses to escalating opioid abuse have been one-sided, resulting in public health crises: 1) terribly treated chronic pain, 2) prescription drug abuse, and 3) susceptibility to addiction.
Dr. Passik’s critical assessment of the state of pain management 5 years after the Decade of Pain was echoed in January of this year with the release of a new report by the National Institutes of Health (NIH) detailing a lack of research into better pain treatment methods and poor preparedness among physicians.1 The report was compiled in response to an escalating problem for clinicians and pain patients alike: the continuing increase in use of opioids for chronic noncancer pain and the concomitant skyrocketing of opioid addiction and overdose deaths. New data released by the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) in late February2 showed that the percentage of adults age 20 and older using prescription pain killers remains significantly higher than in the past, with people also taking stronger painkillers than before. Between 2011 and 2012, nearly 7% of adults reported using a prescription opioid analgesic in the past 30 days, compared to 5% in 2003 to 2006. In 2014, the CDC found that doctors wrote 259 million prescriptions for pain killers in a single year, or a supply of pills enough for every US adult. Prior data from the CDC has also shown that nearly 50 Americans die from an overdose of prescription painkillers every day.
In its January report, the NIH concludes there is a lack of data that favors long-term use of opioids, and that other treatments like physical therapy and alternative and complementary medicine are inadequately considered. Clinicians do not have enough guidance when it comes to prescribing strategies, the NIH notes, arguing that the root of the problem is our overall lack of knowledge of how to effectively treat pain. The NIH says new study designs are needed to better research chronic pain treatment.
Frontline practitioners who are treating chronic pain, according to Dr. Passik—and borrowing from another PAINWeek faculty member—need to be “talented amateurs in addiction medicine.” Clinicians must understand how to assess patient risk, they need to know strategies to contain the risk, and most importantly, they need to know when they’re in over their head. In line with the NIH report assessment, however, Passik believes we haven’t created that generation of practitioners yet.
All this is not to say that progress has not been made. The work of advocacy organizations like the National Fibromyalgia & Chronic Pain Association have done much to speak up for pain patients. And Passik points to multifaceted programs like Project Lazarus which have dramatically decreased opioid deaths without dramatically decreasing opioid prescribing through a coordinated public health approach.