A study of 96 clinical trials came to the conclusion that opioids aren’t very effective for chronic non-cancer pain. The study was published yesterday in the Journal of the American Medical Association (JAMA) and quickly got the attention of news media, reported on with headlines like “Opioids offer little chronic pain benefit and wane over time” (CNN) and “Opioids don’t work well for chronic pain and are overused, study finds” (NBC News).
If I didn’t know much about chronic pain, I’d say wow — it sounds like a great way to solve the opioid crisis would be to just stop prescribing opioids for chronic pain. Indeed, these types of studies are typically used to justify limiting opioid prescribing for chronic pain. But the study is missing the deeper story and challenges behind chronic pain and opioids, and risks making it even harder for people to get relief from their pain.
Here are four things to remember in light of the new JAMA opioid study.
1. We shouldn’t discount that opioids are effective for some people.
The study looked at clinical trials involving using opioids to treat four types of pain: neuropathic pain, nociceptive pain, central sensitization (pain present in the absence of tissue damage), and “mixed types of pain,” and found that on average, opioids provided only a small amount of pain relief. This finding was then summarized in news articles as “opioids don’t work for chronic pain.”
First of all, let’s be clear that the fact that opioids aren’t always effective for certain kinds of pain is not new information. Previous research has questioned the efficacy of opioids when treating nerve pain, for example, and even suggested that opioids can make hyperalgesia and allodynia worse. However, opioids can be used to successfully treat severe pain from chronic illnesses like lupus, arthritis and Ehlers-Danlos syndrome. Every patient is unique, and not everyone experiences opioids the same way. (One thing that is true: most people prescribed opioids for chronic pain do not become addicted.)
But does that mean we should tell everyone using opioids that their medication actually isn’t helping them and they’d be better off, or at least the same, without it? Of course not. The medical community and general population need to accept that, yes, some people don’t find opioids effective and therefore shouldn’t use them, but for others, opioids do work and allow them to have a more functional life. Their treatment shouldn’t be challenged just because it doesn’t work for everyone. The decision to use opioids is a conversation that should happen between each patient and their doctor and should be based on whether or not opioids work for them.
2. People taking opioids don’t expect to have their pain reduced to zero with opioids alone — in reality, opioids are just one tool in their toolbox.
“There are many options to consider when offering treatment for chronic pain that go beyond pharmacological management such as physical therapy, cognitive behavioral therapy, mindful meditation, yoga, and tai chi,” the study authors wrote — as if pain patients have never thought of these ideas before.
You’d be hard-pressed to find a chronic pain patient who has never tried anything to treat their pain besides opioids. Over-the-counter medications, massage, meditation, heating pads, reducing stress, yoga — these are all things pain patients often try beforeopioids. Even when they begin an opioid regimen (typically as a last resort because nothing else has worked), most chronic pain patients incorporate various techniques to manage their pain.
Pain patients are just regular people trying to function in their lives as best they can, and “suggestions” like the ones above make it seem like they’re lazy and clueless about their own health. I think it’s safe to say most pain patients would rather not add yet another medication — with side effects — to their daily routine if they don’t have to. Patients are well aware of opioids’ side effects, stigma and potential for abuse (articles like these, after all, make it impossible to forget) so let’s not treat them like they’re just mindlessly following the crowd and need to be told, “Have you ever tried yoga?” Trust me, they probably have.
3. The study authors concluded that doctors prescribe opioids as an “easy fix,” but more and more evidence suggests doctors are now afraid to prescribe opioids.
The study authors claim that explaining alternative options to patients can be “difficult and time-consuming for clinicians” and helping patients access these treatment options is even more difficult, so prescribing opioids is the easiest option. As we look back at the history of opioids and what led to the opioid crisis of today, there may be truth to the idea that doctors used to prescribe opioids more freely than they do now, not realizing the risk of diversion and subsequent addiction. And it is true that finding effective, accessible, affordable non-opioid options can be challenging (more on that in a minute).
But the tide is turning, and many doctors are moving away from opioids out of fear that patients will become addicted, they will be investigated or even lose their license if they prescribe opioids. A study of 3,000 physicians published earlier this year found that 70 percent had cut back on prescribing opioids — 22 percent because there are “too many hassles and risks involved,” 22 percent because of “improved understanding of the risks of opioids,” and 10 percent because they were afraid of getting in trouble with licensing boards or drug regulators.
A recent report by the Human Rights Watch found that patients are suffering from doctors’ reluctance to prescribe opioids. It’s not unusual for patients to be tapered suddenly, without their consent or a reason beyond demands from insurance companies or doctors’ fear. Some doctors are even refusing to take new pain patients. The study’s authors are woefully out of touch if they think doctors still view opioids as an “easy fix.”
4. Studies like these vilify opioids without offering any viable alternatives, leaving patients in treatment limbo.
We have this study that claims opioids aren’t effective, but what are patients supposed to do with this information? Effective alternatives to opioids are not so easy for patients to access. Things like physical therapy, yoga and heat therapy are not always covered by insurance or affordable out of pocket. Medical cannabis is still not legal at the federal level or in every state. Where it is legal, doctors often aren’t knowledgeable enough to offer real guidance to their patients. Many chronic illnesses are still poorly understood and don’t have many (if any) medications that actually address the root cause of the pain. And patients are sometimes met with ridicule when they try “Eastern” methods like acupuncture and cupping.
All we’re left with is yet another mark against opioids, without any other place for patients or doctors to turn. We’re left with the impression that “opioids are bad” and people with chronic pain should just stop taking them — without acknowledging that they are a last resort and lifeline for many people. Reading studies like this, you get the sense chronic pain patients need to just “suck it up” and learn to live with their pain — which they already do.
The JAMA study tells us that opioids aren’t as effective for some kinds of pain. OK. So… now what? How do we treat people with those kinds of pain? That’s the question we need to be focusing on.