Tens of thousands of Americans are dying from opioid overdoses, but others need them to treat chronic pain. How do we reconcile both sides?
More than 20 years after the first uptick in opioid overdose deaths in the United States, two groups are pitted in a bitter tug of war around the causes of, and solutions to, the opioid epidemic.
On one side are people pointing to over-prescribing as the reason tens of thousands of Americans die each year from opioid overdose. On the other side are people concerned that efforts to constrain over-prescribing are hurting Americans living with chronic pain.
The tension raises a key question: Are efforts to address addiction and pain fundamentally at odds?
The answer is no. The dueling perspectives on the opioid epidemic and its response both have validity, and there is plenty of room for common ground. A starting point is the recognition that millions of Americans with chronic pain are at risk for opioid addiction, and millions with substance use disorders suffer from chronic pain. It is essential for the nation to advance efforts that address addiction and chronic pain at the same time.
There is no doubt that opioids have been oversupplied in the United States, with enough prescriptions dispensed in 2010 to provide every adult in the U.S. a one-month, round-the-clock supply of pills. While prescribing hasdeclined modestly since then, levels remain far above the pre-epidemic baseline, as well as above levels in every other region of the globe.
The risks of opioid use for pain are well established. Studies indicate that about one in four patients on opioids for extended periods will at some point use them in ways other than as intended, with as many as 10% developing opioid use disorder, or addiction. For many patients, these risks outweigh the benefits that opioids might provide, as there is limited evidence of their long-term effectiveness for chronic pain.
At the same time, chronic pain is a serious public health challenge, affecting millions of Americans and costing the economy hundreds of billions of dollars a year. Disparities in the prevalence and treatment of pain translate into a disproportionate burden on already vulnerable populations, such as the elderly and racial and ethnic minorities. When patients who have been stably maintained on opioids are denied further treatment, the result can be severe pain, increasing desperation, a turn to illicit sources of drugs, or even suicide.
There are three major ways to address opioid addiction and pain at the same time.
►First, the health care system should provide people living with pain access to more than just opioids. Opioids, like all prescription medicines, are just one set of tools in a large toolbox. But there is insufficient access to, or reimbursement for, alternatives to opioids. These include physical therapy, counseling, different classes of medications, and consultation with a diverse team of clinicians who may diagnose other treatable conditions and provide specialized care. It is imperative that insurers and policymakers assure access to a broad range of needed services to as many patients as possible.
►Second, health care practitioners should learn how to diagnose and treat opioid addiction. No group of patients is immune from the risks of addiction, which is a chronic illness, not a moral failure. Yet many clinicians have received little to no training in diagnosing addiction, and fewer than 7% of physicians have the authority to prescribe buprenorphine, a safe and effective treatment. Medical authorities including the Accreditation Council for Graduate Medical Education, which oversees medical training, should close this training gap at once, or Congress should take action.
►Third, insurers and regulators should recognize that the best clinical care is both guided by evidence and tailored to the needs of patients. The recent CDC Guideline on opioid use for chronic pain in primary care embodies this concept; it generally advises limiting dosages for patients but at the same time notes that clinicians must consider the individualized needs of specific patients in their application. The agency should both reinforce its recommendations and caution against one-size-fits-all implementation.
It would be irresponsible to turn the clock back to the peak period of opioid prescribing or to overlook the overwhelming evidence that opioids have been used far beyond the evidence base, at great human and economic cost. It would also be inappropriate to embrace forced tapers of stable patients using opioids for pain, or other policies that prevent access to opioid therapy across the board.
The opioid epidemic challenges the health care system to be adept enough to develop effective approaches that maximize the benefits and minimize the risks of opioid medications. A good first step is to end the tug of war between addiction and pain — and focus on ways to make progress against these twin challenges together.
Dr. Caleb Alexander is a professor of epidemiology and medicine at the Bloomberg School of Public Health, where he co-directs the Johns Hopkins Center for Drug Safety and Effectiveness. Dr. Joshua Sharfstein is vice dean for public health practice and community engagement at the Bloomberg School of Public Health, and the co-author of The Opioid Epidemic: What Everyone Needs to Know from Oxford University Press.