I am now spending more time on pain and opioid research than I am on infectious diseases. There’s a dearth of knowledge on the epidemiology of chronic pain. What we keep on hearing about, though, is “the opioid epidemic.” I am currently writing an article for one of the main medical journals, as well as an op-ed, hopefully for one of the major national newspapers, on how this is misspecified and misleading. Without going into the technical arguments, this is because there is no one epidemic, but there are several notable increases in overdoses, each of which has different social and psychological drivers, with the only commonality being the molecules: the opioids.
These include: 1) overdoses of IV and inhaled street drugs, including heroin and more recently fentanyl and its analogues, either alone or in combination with heroin. These account for the majority of opioid overdoses and deaths in the United States. 2) prescription opioids that are not legitimately prescribed but are stolen, diverted, or otherwise obtained; 3) legitimately prescribed opioids that are diverted; 4) legitimately prescribed opioids that are not used as directed; 5) legitimately prescribed opioids that are used as prescribed. In other words, some of the opioid deaths are because the victim is trying to experience the euphoria of the recreational drug, and others for a variety of reasons. Most in the latter categories are not due to opioids alone, but rather to opioids used in combination with other respiratory depressants, notably the benzodiazepines, such as alprazolam (Xanax) and diazepam (Valium). This can be lethal in combination with opioids. In addition, alcohol can be a potent respiratory depressant.
With increasingly tight restrictions on prescribed opioids, it’s been noted qualitatively that many are turning to street drugs not to get high, but in a search for medication for their pain. Obviously this is not ideal. Even purchasing street drugs may be a search for pain treatment.
There is another kind of pain. That is psychic pain. The pain of poverty, anomie, alienation, despair, depression, anxiety, and fear over the future. We see this in areas where opioid overdoses are prevalent. At a fine geographic scale, nobody knows the correlation or the cause, and this is one thing that the team that I work with is trying to identify, along with hotspots of opioid prescribing and opioid deaths.
Opioids are rarely the treatment of choice for chronic pain, yet sometimes, perhaps as third line medications, or in combination with other treatments, including medications such as the tricyclic and other antidepressants, they can be effective. Some of the best responses for chronic pain are to improve sleep patterns (antidepressants, meditation, or anticonvulsants) , mobilization and graded/gradual exercise, cognitive-behavioral therapy, mindfulness meditation, and some of the anticonvulsants. Not as frequently mentioned is the positive effect of a good therapeutic or doctor-patient alliance. Less frequently mentioned, though increasingly noted, is the potential of cannabis in the treatment of chronic pain. Just as there is an endogenous opioid system, so there is an endocannabinoid system in the body. Unfortunately, it is extremely difficult to do cannabinoid research in this country because of the scheduling of cannabis by the FDA. We are lucky to have some very talented prescribers of cannabinoids in our area. I must call out Sunil Aggarwal, MD, PhD, in this respect, who did his PhD with me, as part of our MD-PhD program. He certified in both Palliative Care and in Physical Medicine and Rehabilitation (physiatry).
In the end, though, there is no one opioid epidemic, and it is wrong to pretend that there is. “The opioid epidemic” is a rhetorical term that has caught on and we hear it again and again, and rarely is it used carefully. Instead, we see the intrusion of various government units into restrictions in prescribing, and the inscription into law of these restrictions. In short, the state is practicing medicine. What is really needed are some sensitive and specific tools to predict who will benefit and who will not benefit from longer term opioid use, and who might be problematic and who will probably not be problematic in terms of the transition to addiction. Even more profoundly, we need to address the underlying causes of despair and alienation.