January 31, 2019

Tackling opioids: Rethinking a ‘medicalized’ approach to pain

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Health care providers are addressing harm caused by overtreatment with narcotics while finding new ways to treat pain more safely.

By Eric B. Larson, MD, MPH, Kaiser Permanente Washington Health Research Institute executive director, and Kaiser Permanente Washington vice president for research and health care innovation

Pain is a universal experience for all living creatures. And nearly every person will experience enough chronic pain to seek medical care at some time in their life—for headaches, back aches, severe joint pain, and the like. As we age, chronic pain becomes even more common.

There’s no one-size-fits-all answer to this everyday human experience. Over time and place the approaches to pain have varied. And conscientious health care providers have always sought to help relieve their patients’ pain and attendant suffering.

As a physician and researcher studying resilience in older populations, I’m always intrigued with people who beat the odds. I’m interested, for example, in those who struggle with conditions like osteoarthritis and yet manage to stay active without using harmful narcotic medications. So, when I heard about a woman I’ll call Nan—the 78-year-old friend of a friend who lived with debilitating back pain—I wanted to share her story.

Changing how we think about—and experience—pain

Nan had always taken great care of herself—eating well, swimming and walking regularly, taking art classes, singing in a choir. By her mid-70s, however, she developed unrelenting back pain. Physical therapy helped a bit, but over time, standing and walking became more difficult. So she spent increasingly more time on the couch, binge-watching old TV shows. 

Nan’s doctor diagnosed a spinal disorder and suggested fusion—a surgery that uses bone grafts and metal rods. But her lab evaluation showed she had osteoporosis severe enough to prevent the bone from fusing properly after the operation. Learning this, Nan felt devastated. She had viewed surgery as her last resort, and now there would be no surgery. She wondered if she could ever have her old life back again.

In the months that followed, however, something remarkable happened. Through hypnotherapy, Nan started to change the way she thought and experienced her back pain. The pain didn’t go away. But she realized that doing the things she loved—walking to her painting class or standing to sing in the choir, for example—would require accepting some level of pain. Nan could choose an active life over her immediate comfort. So that’s what she did. 

Nan also discovered that being more active distracted her from her pain, lifted her spirits, and helped her feel better overall. Now she’s spending less time on the couch, more time doing the things she used to do, and enjoying her life despite her back pain.

Hearing Nan’s story, I am reminded of two things. One is the power of the mind and spirit to overcome pain—an area ripe for scientific exploration. The other is the tremendous challenge ahead as our nation seeks to recover from one of our biggest public health challenges: Our current epidemic of opioid drug overuse.

Was it wrong to think pain could be eradicated?

Here’s the heartbreaking reality of the opioid overuse epidemic as I see it: Doctors and patients alike were led to believe that drugs like Oxycontin, Vicodin, and Percocet were the magic solution to one of life’s universal problems. Our field made a conscious effort to “medicalize” pain as though pain alone were a disease state. Pain became a new vital sign, so we adopted the idea that health care teams should routinely monitor pain. Many believed it was the provider’s job to not just reduce pain, but to eradicate it. At the same time, we were falsely taught we could easily do this with prescription opioids, which were thought to be effective, nonaddictive, and mostly safe. “People with pain can’t become addicted to pain meds,” we were told.

But now—thanks in large part to research from organizations such as ours—we know that previous “best practices” and “standards of care” were wrong. In fact, they were based on false information promoted by some elements of the pharmaceutical industry. Today’s evidence shows that most patients who take opioids for chronic noncancer pain do not benefit from these drugs. In fact, many become addicted and their quality of life diminishes as a result. Tragically, many die from accidental overdose. Prescription opioid overdose results in about 46 U.S. deaths a day, according to the Centers for Disease Control and Prevention. The U.S. National Safety Council reports that Americans are now more likely to die from accidental opioid overdoses than car crashes.

Scientists at Kaiser Permanente Washington Health Research Institute (KPWHRI) were among the first to sound the alarm in 2010, publishing a study that showed patients receiving higher doses of prescribed opioids for chronic noncancer pain were at higher risk for overdose. Our subsequent work with Kaiser Permanente Washington providers and others led to Washington state guidelines and a Kaiser Permanente Washington initiative to increase safety and ideally reduce chronic opioid prescribing. Our work to address the opioid crisis continues as Kaiser Permanente Washington scientists and providers lead efforts to reduce opioid prescriptions and lower dosages.

Other recent examples of our efforts: Kaiser Permanente Washington’s recent opioid management initiatives that established a new, multidisciplinary pain-care consultation team to support providers in creating care plans for complex patients with chronic pain. Part of this broader regional initiative also provides trained pharmacists to support patients tapering off opioids, including with regular outreach to patients and their providers. In addition, our researchers are currently conducting a trial funded by the National Institute on Drug Abuse that will determine whether pain self-management training can promote prescription opioid taper without increasing pain levels or interfering with activity.

Plus, we’re working with other health care stakeholders through organizations such as the Bree Collaborative, contributing to its recently published recommendations for collaborative care for chronic pain.

Mind/body approaches provide safe, affordable alternatives

Efforts like these are helping to turn the tide. We’re addressing harm caused by overtreatment with narcotics and we’re finding new ways to treat pain more safely. As the pendulum swings back, some health care providers may err in the opposite direction—not treating pain at all, leaving people with no strategies to cope with their suffering. But we shouldn’t allow that to happen. There are many nonopioid-related approaches that can help relieve pain and give people their lives back.

Some of the most important research to date on nondrug strategies has been done here at KPWHRI in our long-standing program on alternative treatments for chronic pain. Our studies of mindfulness-based stress reduction, yoga, massage, acupuncture, and more have led the field. They are helping to establish Kaiser Permanente Washington as an international thought leader in understanding mind/body approaches that are drug-free, affordable, and associated with other health benefits in addition to addressing pain.

Now we’re parlaying this leadership in pain research to make a further difference. Examples include current projects such as:

  • A study funded by the National Center for Complementary and Integrative Health that marries concepts from the field of implementation science to education in mindfulness-based stress reduction, finding ways to make it attractive for today’s busy person. If successful, findings could help lead more people with chronic pain to try this alternative approach.
  • A National Institutes of Health-funded study that compares usual care for chronic pain, including prescription opioids, to a multipronged primary care intervention that helps patients limit opioid use and uses self-management skills including behavioral skills training and yoga.
  • A study examining a new Oregon Medicaid reimbursement policy regarding nondrug back pain treatments—i.e., physical therapy, cognitive behavioral therapy, yoga, acupuncture, spinal manipulation, and massage. Funded by the Patient-Centered Outcomes Research Institute, results may tell us how the change affects patients’ pain severity, function, and use of illegal and recreational drugs.

Our nation faces a sobering challenge in addressing opioid overuse. We need to rethink the notion that with opioids we can somehow safely eliminate pain. At the same time, we must meet the needs of our members and providers, including an aging population who will increasingly be seeking compassionate, effective care for the many common and uncommon causes of chronic pain.

I am heartened by the work our experts at Kaiser Permanente Washington are doing to develop evidence-based solutions and evaluate them in real-world practice. Through research and implementation of our findings, we can address care for chronic pain, improving the lives of Kaiser Permanente members. And by sharing our learnings with others, we can improve lives in the communities we serve and around the world.