Canada and the U.S. have seen alarming increases in opioid prescribing and in opioid-related overdose deaths. Prince's tragic opioid-related death further highlights this international public health problem.
Indeed, the spectre -- and reality -- of opioid limits have sent shockwaves through segments of the chronic pain community. The vast majority of individuals prescribed opioids take them responsibly, yet are now subject to laws created to prevent illicit opioid use.
Patient advocacy groups have loudly decried unjust medical care for chronic pain. Limiting opioids may preclude some opioid overdose deaths, they say, but what about the untold suffering -- and the suicides -- that may occur when patients cannot tolerate severe ongoing pain? The lives of people with chronic pain matter, too, and they should be treated as patients, not as addicts.
It's a Catch-22, of course. The opioid debate engenders strong emotions for both sides: opioid access versus limits. Is it really a zero-sum game where one group must suffer so the other group may survive?
Even when opioids are taken exactly as prescribed by exemplar patients, they come with a range of health risks including overdose fatality. How do we address the need to reduce health risks while treating chronic pain?
Do opioids help some people with chronic pain? Absolutely. For this reason, prescribers must retain discretion to prescribe them, while recalling that it will be for a minority of patients. Opioids may help, but they can't be the whole story.
We don't have good data to show that the average person taking opioids long term gets better in terms of pain or function. Some people do, but studies show that most do not. However, we do have data to show that most people have side-effects that are not trivial. Some opioid side-effects include worsening pain, escalating opioid doses due to increased pain sensitivity or tolerance to the medication, altered hormones, constipation, and sometimes -- fatal overdose.
The problem is, we do not have national systems in place to treat chronic pain otherwise. This is the larger Catch-22 that simply must be addressed. It's time for national governments to put their money where their mouth is and to focus on major pain research initiatives and comprehensive treatment programs that will allow us to treat pain better.
We know that opioids alone are also not a great chronic pain treatment strategy. Studies show that patients improve with combined treatment that includes gradually becoming more active, while also using other key self-management skills. All physical pain is processed in the nervous system (brain and spinal cord). People with chronic pain can regularly use simple skills to dampen pain processing in their own nervous system. They can reduce their own suffering, pain and need and use of opioids.
Will it cure pain? No. Will it help reduce need for medication? Often, yes. Will it reduce suffering?
As a pain psychologist, I share patients' concerns about limiting opioids without providing access to alternatives. In and of itself, limiting opioids is not a pain care plan. Canada and the U.S. are now tasked with rapidly providing its citizens with access to opioid alternatives for chronic pain.
Ethical pain care should emphasize first the programs and initiatives that empower individuals to best control their own pain. When people are equipped to help themselves feel better, they need fewer doctors and treatments.
Excellent chronic pain self-management programs exist. It's time we subsidize patient empowerment programs; doing so will give physicians and other prescribers the resources needed to treat chronic pain better.
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