Medicine needs to do right by people living with chronic pain7 min read
As a medical student, the prism of pain helped me begin seeing patients as people — discerning their stories, examining their bodies, understanding their lives, and more. In medical schools around the world, the first simulated patient students encounter to emulate the rituals and mannerisms of medicine is someone in pain. Yet chronic pain, particularly the kind not emanating from a broken bone or an inflamed appendix, seemed like a distant, hazy concept for me.
That changed when, one day while exercising, I heard a loud click in my back and the metal bar I was holding with 200 pounds of weights came crashing down on my chest, pinning me to the bench.
Fourteen years later, I am still living with the aftermath of that incident. While I initially feared that this injury would end my medical career, it has gone on to indelibly shape how I view others in affliction, giving me hard-won insights into the plight of the 50 million Americans living with chronic pain, many of whom the medical establishment has harmed through acts of both commission and omission.
A story a friend and colleague shared with me illustrates the wretched state of those in unremitting agony and the difficult choices their physicians face. Joe (not his real name) had chronic back pain like me, and while he had seen many physicians, he really connected with my friend, a primary care physician who was newly out of training. Joe was taking OxyContin for his pain, but followed all the rules such patients are expected to abide by: He never ran out of his prescription earlier than he was supposed to, never inundated the clinic with phone calls seeking refills, never demonstrated behaviors that would give him the dreaded “drug-seeking patient” label. Yet his pain got worse and my friend, noting Joe’s good behavior, continued to reluctantly ratchet up his opioid dose, which seemed to allow him to live his life on his own terms.
When Joe moved to California three years later, the new doctors he connected with were horrified at the high dose of OxyContin he was on. Worried that he might overdose, they began cutting back on his dose. While this caused Joe to go into withdrawal, his new doctors did not change course. Joe turned to heroin he was able to get on the street, and not long after died of an overdose.
This story, which I shared in my new book, “The Song of Our Scars: The Untold Story of Pain,” encapsulates the sordid entanglement of America, chronic pain, and opioids.
In the 1980s, doctors were so fearful of opioids that they preferred not to prescribe them — even to people with excruciating cancer-related pain. Calls to improve the treatment of pain, such as exhorting clinicians to include pain as the fifth vital sign (along with body temperature, heart rate, breathing rate, and blood pressure), made clinicians less gun-shy about using opioids aggressively.
At the same time, companies like Purdue Pharma were marketing a new breed of pain-killing drugs that they falsely claimed were not addictive.
This toxic union led to millions of Americans becoming dependent on opioids. Between 1999 and 2019, 500,000 died from opioids, with a record 75,673 dying between April 2020 and April 2021.
As the medical community finally became sensitized to the dangers of these drugs, aggressive and at times ham-handed attempts at cutting people off painkillers, such as happened to Joe, caused many people living with chronic pain to move toward using illicit opioids like heroin and fentanyl, which only further increased the overdose risk. And when the Covid-19 pandemic emerged, the overdose crisis got worse: more Americans died of opioids last year than any in recorded history. As clinics shuttered, opioid prescriptions dropped, and rehab facilities closed, some people may have switched to illicit fentanyl or heroin. Unprecedented job loss and social isolation, cessation of harm-reduction services, and increased contamination of illicit narcotics with the far-more-lethal fentanyl may also have tipped many opioid users over the edge.
The medical community played a primal role in setting off this pandemic through reckless opioid prescription, so it is only right that it should shoulder the responsibility for patients who have been prescribed opioids to treat chronic pain.
While opioids are an almost miraculous balm for acute pain, they aren’t a great therapy for chronic pain. Not only do they carry well-documented harms, but they aren’t that effective at treating chronic pain: An expansive review of studies conducted by the federal Agency for Healthcare Research and Quality found that opioids were no better for treating chronic pain than safer painkillers like ibuprofen or acetaminophen. In fact, a major randomized trial showed that people with moderate to severe back or joint pain who took opioids actually had more pain than those who took safer non-opioid medications.
Why? Opioids actually lower the threshold for pain by suppressing the body’s innate mechanisms for relief.
Even with this knowledge, a blunt approach toward taking people off opioids can be dangerous. A recent study of patients covered by Medicaid found that abrupt discontinuation of opioids is associated with an increase in death and suicide. This risk was not reduced by the fact that these patients were more likely to be prescribed buprenorphine, the drug used to mitigate the pangs of opioid withdrawal. Yet the same study also revealed the kind of dilemma patients and clinicians find themselves in: Compared to those whose opioid dose was reduced or discontinued, those with a stable or increasing dose of opioids did no better since they had a greater risk of fatal overdoses.
The risks of a patient either continuing to take opioids or stopping them make one thing clear: Starting anyone on opioids is one of the most important decisions any clinician can make. However, while 76% of American patients pick up prescriptions for opioids after low-risk surgery, only 11% of similar Swedish patients take opioids. Even such a short course of opioids can be risky. One study found that for 29% of heroin users, their first opioid came from an emergency room. In 2016 alone, American dentists wrote 11.4 million prescriptions for opioids, a proportion 37 times higher than English dentists. This is particularly significant since 5.4% of individuals given opioids by their dentist develop opioid use disorder. The irony is that people prescribed opioids after a dental visit actually report higher levels of pain than those given non-opioids.
Physicians need to be particularly cautious when starting opioids in patients who research suggests are at the highest risk for developing addiction: those with a history of mental health or substance use disorders. Yet in one study, patients reported not being provided information regarding the rocky road any patient on chronic opioid is likely to experience. “I don’t know why (clinicians) don’t tell you more about these mediations before they prescribe them!” a patient told researchers. “It’s like knowledge is power, and they don’t want you to have that power.”
“I needed that explained to me in layman terms,” said another patient, “…rather than saying here’s your tablets, see you later.”
Stopping opioids or reducing the dosage without offering a patient adequate resources or alternatives can be dangerous and can fracture the patient-doctor relationship even if it is done with good intentions.
The Veterans Health Administration (VA), a health care system I work in, offers a model of how do this right. Between 2012 and 2020, the VA reduced opioid prescription by 64%. Reductions achieved in higher-risk categories were even more marked: an 87% reduction in patients prescribed opioids and benzodiazepines together, which can be a particularly lethal combination; and an 80% reduction in patients on very high doses of opioids.
Underlying these safe reductions was the fact that the VA provides access to the gold-standard of chronic pain care — interdisciplinary pain management — which offers evidence-based therapies like exercise, acceptance and commitment therapy, and hypnosis, in addition to procedural and pharmacologic options. While most VA facilities offer multidisciplinary pain management, this kind of service has been on the decline elsewhere. Accredited interdisciplinary pain rehabilitation programs in the country declined from between 1,500 to 2,000 in the 1990s to just 74 in 2022, 17 of which are in Texas.
Health care needs to acknowledge its role in overdose-related deaths. But solemn reflection is not enough. Unless patients are provided interdisciplinary pain management options, opioid deprescription is nothing more than an abdication of responsibility.
Interventions like physical therapy helped me survive my own encounter with chronic back pain. Far too many others aren’t as lucky as I have been. To recalibrate how clinicians treat patients in unrelenting agony, they must adopt an approach rooted in empathy, with ample access to the myriad tools — including opioids if needed — that can safely help those in extremis.
Haider J. Warraich is a physician at the VA Boston Healthcare System and Brigham and Women’s Hospital, an assistant professor at Harvard Medical School, and the author of “The Song of Our Scars: The Untold Story of Pain” (Basic Books, April 2022). The views expressed here are his and not necessarily those of his employers.