We’re all aware of the weaknesses of current strategies for treating pain, but perhaps not as up to date on the search for better options. Here’s an opinionated but well-organized piece on the evidence for various approaches to back pain, the most common type.
Having suffered from this at several points during my life, I appreciate just how difficult it can make things. I like to joke that any politician who promised to care for back patients would be guaranteed a win. “Sure, he’s been to prison,” a supporter could argue, “but if he takes care of me when my back goes out, he has my vote.”
Coincidentally, another article appeared the same week, focusing on the problem from a slightly different viewpoint:
Seems clear to me that it’s the patients who are driving innovation here. With some exceptions, healthcare research continues to lag behind. Thankfully, the need for alternative treatments does appear in the early recommendations of the Opioid Commission. Perhaps some NIH funding could be directed there.
When the push to use more opioids for pain began, we heard that there were 100 million chronic pain patients in the United States, most of whom were untreated (or undertreated). I was never sure where that figure came from. The research was full of caveats, such as:
- Lack of standardized methods, definitions, & survey questions, both across and within agencies.
- International standard questions were not consistently used on US surveys
- Surveys excluded military personnel, nursing home and chronic care patients, and corrections populations.
- Data was available for only a few conditions, such as arthritis and low back pain.
- There weren’t clear distinctions between acute and chronic pain.
- Data on consequences of pain was often old.
It may be that we still lack an accurate picture of pain in America. Particularly chronic pain, which is so broadly defined — any pain that persists for several months — as to be almost without real meaning.
So why the reliance on opioids, despite the adverse consequences? My guess is that from a practitioner standpoint, there are several key advantages:
- The patient leaves the office with a prescription, feeling as if s/he has received something of value from the visit. That results in better patient satisfaction ratings.
- Opioids do relieve pain.
- The bill is paid promptly by a third party payer.
The disadvantages become obvious later:
- Opioids carry risk: for misuse, abuse, dependence, and addiction. And diversion.
- That initial relief may not last beyond a few weeks. Over time, opioids may actually contribute to continuing pain (hyperalgesia).
- Increasingly, practitioners are being monitored for overuse.
In that respect, we may need to make substantive changes in how the healthcare system operates. I suspect there are some very bright people at work on this right now. When solutions are available, however, we’ll need the will to implement them.