Balancing the Opioid Crisis with Compassionate Pain Management

Overprescribing opioids in the first decade of the 21st century led to a rash of addictions and deaths. In response, regulators drastically limited prescriptions and succeeded in curbing addiction and overdose rates [1]. However, pain management remains important for medical professionals, particularly to help patients with chronic pain. Some practitioners have suggested a new prescribing framework based on individual patient’s needs, while others argue that psychological techniques can be used to mitigate the risk of addiction for patients taking opioids for chronic pain. 

The link between prescription opioids and abuse is well established. Chou et al. summarized the existing literature by pointing out that overprescribing opioids is associated with a host of problems, including addiction and death from overdose [2]. Indeed, prescriptions for opioid analgesics increased steadily starting in 2002, and deaths associated with them rose in parallel. When prescription levels began to drop in 2010, deaths from overdosing dropped as well. Yet serious damage had already occurred. During this period, roughly 25 million people started using pain relievers in non-medical contexts, and deaths linked to prescribed opioids peaked at 16,651 per year [3]. Some practitioners fear that an anti-opioid backlash has become punitive for patients and worry that doctors, in a well-meaning attempt to keep their patients safe, may be depriving them of the only means they have to fight pain [4]. In fact, some worry that under-prescribing opioids will erode doctor-patient trust and wonder how doctors can form relationships while divesting patients of medications they rely on [5].  

Some practitioners support a patient-centered approach in which pain medication is prescribed after a careful risk-benefit analysis. Rothstein argues that, to the extent that doctors fear causing harm (or malpractice lawsuits) after overprescribing opioids, they should also be wary of causing harm by not sufficiently responding to patient complaints about pain [5]. Nicolaidis attributes both over- and under-prescribing to a skewed doctor-patient relationship. Pointing out that doctors often treat pain medication as a reward for trustworthiness—and retract it in a punitive manner when patients are deemed insufficiently trustworthy—Nicolaidis urges a new approach in which pain relief is divorced from perceptions of virtue [6]. Still others suggest an emphasis on prescriber education, allowing doctors to confidently offer pain treatment options based on an expert evaluation of the patient’s needs and risk factors [1].  

As Chou points out, few studies have rigorously evaluated techniques for reducing addiction among chronic pain sufferers [2]. Closer study of such methods may allow doctors to treat pain with opioids while keeping addiction and abuse low. A study by Dhokia et al. sheds light on potential techniques to ease the likelihood of addiction and abuse among at-risk groups. The study split adult pain sufferers with concerns about their own analgesic reliance into randomized groups—one was assigned to practice Compassionate Mind Therapy (CMT), the other was assigned to listen to relaxation music. The CMT group showed a greater decrease in prescription analgesic dependence to the control group, with an F-value of 14.322. They also demonstrated a greater decrease in negative psychological factors such as self-hatred, with an F-value of 12.218. This suggests that psychological techniques such as CMT may be used to help patients with chronic pain avoid analgesic dependence [7]. 

While health professionals readily acknowledge risks in opioid prescription, not all believe that legal restrictions will solve the problem. Instead, they urge a patient-centered approach, emphasizing mutual trust between patients and prescribers while seeking techniques to reduce the likelihood of addiction and reliance for those who find opioid analgesics most effective. 

References 

[1] Alford, Daniel P. “Opioid Prescribing for Chronic Pain — Achieving the Right Balance through Education.” New England Journal of Medicine, vol. 374, no. 4, 2016, pp. 301–303., doi:10.1056/nejmp1512932. 

[2] Chou, Roger, et al. “The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop.” Annals of Internal Medicine, vol. 162, no. 4, 2015, p. 276., doi:10.7326/m14-2559.  

[3] Dart, Richard C., et al. “Trends in Opioid Analgesic Abuse and Mortality in the United States.” New England Journal of Medicine, vol. 372, no. 3, 2015, pp. 241–248., doi:10.1056/nejmsa1406143.  

[4] Christo, Paul J. “Opioids May Be Appropriate for Chronic Pain.” The Journal of Law, Medicine & Ethics, vol. 48, no. 2, June 2020, pp. 241–248, doi:10.1177/1073110520935335. 

[5] Rothstein, Mark A. “The Opioid Crisis and the Need for Compassion in Pain Management.” American Journal of Public Health, vol. 107, no. 8, 2017, pp. 1253–1254., doi:10.2105/ajph.2017.303906.  

[6] Nicolaidis, Christina. “Police Officer, Deal-Maker, or Health Care Provider? Moving to a Patient-Centered Framework for Chronic Opioid Management: Table 1.” Pain Medicine, vol. 12, no. 6, 2011, pp. 890–897., doi:10.1111/j.1526-4637.2011.01117.x.  

[7] Dhokia, Mayoor, et al. “A Randomized-Controlled Pilot Trial of an Online Compassionate Mind Training Intervention to Help People with Chronic Pain Avoid Analgesic Misuse.” Psychology of Addictive Behaviors, 2020, doi:10.1037/adb0000579.