Opioids: Misuse, Restrictions and Communication

“A good scalpel makes a better surgeon. Good communication makes a better doctor.”

- Dr. Josh Umbehr

I came to remember this when I read the latest issue of Annals of Family Medicine (July/August 2012) presenting two papers about chronic pain and opioids. One of the papers is by Dr. John A. Zweifler from University of California. Zweifler advises clinicians to insist upon objective evidence of severe disease before prescribing opioids for chronic pain. Zweifler notes that guidelines call for the use of assessment of pain and its consequences, but Zweifler find that since they are based on subjective patient responses, not objective measures, they must be taken cautiously “until we have measures of pain itself”.

Zweifers paper gives rise to some very important considerations. First I am sure we can agree that we are not able to provide objective evidence for all causes of pain, but does this mean that we should not help our patients the best we can?  Secondly are we going to accept the subjectivity of the pain experience “until we have measures of pain itself”? Thirdly how can we improve safety in opioids prescribing and reduce the increasing misuse? All these three factors are wined into each other.

It seems to me both impossible and meaningless to be able to “measure pain itself”. Even if we could make that measure it would not have any clinical importance since we know, that the experience of pain, which is what the patient respond and react to, is under influence by many other factors like depression/mood, sleep, function, social interactions, work related issues, and much more. All this is mixed and balanced in the central nerve system, and interpreted in the brain resulting in the subjective experience of pain. So the experience of pain and its respond to treatment are subjective in nature, can only be subjective, and discussing its validity and its significance is as meaningful as discussing with your children whether you like rap-music or not. It is, like pain, a matter of a subjective experience, and can just like pain not be measured nor argued, because of this subjectivity.

Presence of concomitant depression with chronic pain increases the risk of misuse of opioids, when defined as using opioids for stress or sleep and using more than prescribed.  Increasing depression score leads to an increasing risk of misuse of opioids. Alicia Grattan and colleagues present this in a paper in the same issue of Annals of Family Medicine. Even though opioids might reduce pain it might also be able to reduce the burden of pain by its cognitive- and calming effects, but where opioids can be part of treating pain, depression and anxiety or sleep problems should not be treated by this, but instead by relevant treatment. If these patients are asked if they “feel better”, they might answer “yes”, this might be due to reduction in pain experience but might also be du to its calming effects. Or by both. We can only find out by assessing not just the pain but also mood, sleep, function and so on, and then evaluate together with the patient.

Death due to prescribed opioids has been rising dramatically, and there are every good reasons to be alarmed. When cars became more dangerous due to more traffic and higher speed, we didn’t forbid cars or, we got the drivers license and learned to drive based on rules and a constant evaluation of the traffic, weather and other factors. Likewise education for BOTH physicians AND patients in the risk and benefits of opioids and how to navigate in this field is crucial. Opioids are best in acute pain, we have only poor data on their use in long term, and alternatives must be first line treatment. If starting on opioids or increasing the dose doesn’t lead to clinical improvements, there is no reason for continuing or increasing the opioid, but instead look for other treatments medical or not-medical. If depression is present it must be treated best possible before just increasing opioids. Chronic pain is chronic, and pain management is an ongoing process with constant assessment, adjustment of treatment and evaluation by the clinician and the patient together. Insisting upon objective evidence of severe disease before prescribing opioids for chronic pain is not what we need, instead we need education, awareness and assessment of the different components of chronic pain – like depression – and treating them best possible, not just prescribe opioids and increasing the dose or let the patient do it. This way the treatment is based on knowledge and is evidence based at the individual level.

Zweifler, J.A., 2012, Objective evidence of severe disease: opioid use in chronic pain, Ann Fam Med, 10(4), pp. 366-8

Grattan, A., Sullivan, M.D., Saunders, K.W., Campbell, C.I. & Von Korff, M.R., 2012, Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse, Ann Fam Med, 10(4), pp. 304-11

Kim Kristiansen, M.D. (2012). Opioids: Misuse, Restrictions and Communication Picture of Pain Blog