The use of opioids to assuage end-of-life cancer pain is the incontrovertible standard of care. The use of opioids to treat chronic non-malignant pain, defined as pain that has lasted longer than 3 months, which is the time necessary for normal tissue healing, is the subject of debate.
Chronic non-malignant pain in this post will be called chronic pain.
The incidence of chronic pain in patients with substance abuse disorders is significantly higher than that of the chronic pain prevalence in the general population. (1) This leads to a necessary question which is should a potentially addictive opioid drug be the therapy of choice for a patient in chronic pain in the first place?
So well documented is the association between chronic pain and substance abuse, that research is ongoing into clinical protocols using opioids with lower abuse potential for such patients.
Interestingly, in spite of increasing opioid prescriptions, studies have not shown an inverse relationship between the use of opioids for chronic pain and the overall prevalence of chronic pain. In other words, opioids are not solving the chronic pain crisis.
In August 2016 US Surgeon General Vivek H. Murthy, M.D. wrote a letter to every physician in America asking them to "turn the tide on the opioid crisis" noting that since 1999 opioid overdose deaths had quadrupuled, opioid prescriptions had increased, and the number of Americans in pain has not decreased.
Founded in 1951, the Joint Commission is the nation's largest independent non-profit standard setting and accreditation organization, serving approximately 20,000 hospitals and health organizations. One of the purposes of the Joint Commission is to guide health care organizations in the areas of patient safety.
In response to the opioid crisis the Joint Commission revised their pain management standard. These amendments state that health care organizations’ treatment strategies for chronic pain need to include both pharmacologic and non-pharmacologic approaches, and that the intervention risk versus benefit needs to be considered, in other words, a patient's substance abuse history needs to be taken into consideration. Non-pharmacologic interventions mentioned include acupuncture therapy, chiropractic therapy, osteopathic manipulative therapy, massage therapy, physical therapy, relaxation therapy, and cognitive behavioral therapy.
The dependence of the health care industry on pharmaceutical drugs is driven by several factors. There is a lack of policies in place in emergency departments to refer pain patients out for the non-pharmaceutical interventions listed above, and there is a failure of hospitals and their out-patient facilities to offer them.
There is a disparity in the financial interests promoting pharmaceutical drugs compared to non-pharmaceutical modalities. The plethora of pharmaceutical drug advertisements on television and in magazines are evidence of this.
And lastly, health insurance policies are driving pharmaceutical drug use. According to the National Institute of Health (NIH) January 22, 2016 report, the use of non-pharmaceutical modalities among adults has increased, independently of health care coverage. In 2012 60% of respondents who had chiropractic care had at least some insurance coverage for it, but only 25% and 15% had some coverage for acupuncture and massage therapy respectively. Medicare does not offer acupuncture benefits.
An example for states to follow
Efforts are being made to reduce the number of opioids being prescribed. West Virginia passed Senate Bill 273 on January 15, 2018, which requires physicians to refer patients for chiropractic care, acupuncture, massage therapy, occupational or physical therapy before prescribing an opioid, and it requires insurance companies, Medicaid, Medicare and Public Employees Insurance Agency, to pay for the non-pharmaceutical care. In addition, the bill limits the number of times a physician can prescribe opioids before referring a patient to a chronic pain clinic.
While such policies are helpful, patients ultimately need to be educated about the risks and alternatives to opioids, doctors need to make the referrals and patients' insurance companies need to pay for the non-pharmaceutical care.
(1) Opioids and the Treatment of Chronic Pain: Controversies, Current Status, and Future Directions. A Rosenblum, L Marsch, H Joseph, R Portenoy. Exp Clin Psychopharmacol 2008 Oct 16(5): 405-416.