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Steven Passik: To Use Opioids Safely, We Need to Stop Blaming the Drugs

Steven Passik: To Use Opioids Safely, We Need to Stop Blaming the Drugs

Picture of William Heisel
Steven Passik, William Heisel, Reporting on Health, chronic pain, addiction, health journalism

I contacted Steven Passik, a professor of psychiatry and anesthesiology at Vanderbilt University, about a paper he had co-authored for the November 2010 edition of the American Journal of Bioethics. He invited me to come hear him speak at Pain Week in Las Vegas next month. I wish I could be there. His talk is titled “Jesus, Bacon, and Hyperalgesia: Intellectual Honesty and Dishonesty in Opioids for Chronic Pain Management.”

One can only imagine the type of post-panel discussion that one will generate. Passik writes about pain management after having worked in academia and with industry. He has received research grant support from Cephalon and Ligand Pharmaceuticals and has been paid as a consultant for Cephalon, Ligand Pharmaceuticals, Eli Lilly and Company, Janssen, and King Pharmaceuticals, Inc. I asked him to share some of his thoughts with all of you.

Here is his guest post:

steven passik, william heisel, reporting on health, opioids, pain treatment, chronic pain

As a person who was trained in both pain and addiction, I have felt the need to throw my weight from one side to the other as the pendulum on opioids swings back and forth. There are millions of people in the US suffering from chronic pain. The idea that any one therapy – opioids, physical therapy, surgery –  is right or wrong for all or even most of those people is absurd and an argument not even worth having.

When the opiophiles were trivializing addiction in the early days, I was seen as a bit of a party pooper talking about the risks and cutting back on the rhetoric. I wrote a letter to the editor to Journal of Pain and Symptom Management in 2001 warning about prescription drug abuse, which is one of the most referenced things I have ever written. I should note that I don’t think of everything the opiophiles were pushing for was quite as diabolical as has been being made out in retrospect. It was a naive and almost religiously well-intentioned movement in those days. People really thought that if we "liberalized opioids" pain would be eradicated.

Compare that to today. I have patients on stable doses of opioids, with no histories of misuse or abuse, some with histories of cancer, being turned away by prescribers running scared of new laws and/or harboring views of opioids in which they believe that addiction, tolerance, hyperalgesia, which is an increased sensitivity to pain, and other negative effects of opioids are inevitable. And they blame the drugs themselves for the problem as if addiction lives in drugs; or as William Burroughs put it, “Addiction is a disease of exposure.”

This is the first mistake of the opiophobes. Blame the opioids themselves. In fact, we have never had a health care system that allows for their safe, individualized (tailored to the person) use.

If I speak to a group of doctors over dinner, nearly all of them will have a cocktail or a glass of wine in front of them. And as a teaching exercise, I might ask them whether alcohol is an addictive drug? They all raise their hands to say they think it is. And so I ask them “why are you drinking then? Aren’t you afraid you could lose it all?” The docs know that alcohol exposure in the US is nearly universal, with the exception of certain religious groups. Yet the rate of alcoholism is 8% of American adults.

Alcoholism is the end result of exposure to alcohol in people with psychiatric, genetic, spiritual and familial vulnerabilities at vulnerable times in their lives (i.e., during times of stress). The same is true of all drugs, including opioids. Addiction is the result of exposure to a substance in a vulnerable person at a vulnerable time.

In pain management, no exposure of anyone at all means cutting off an avenue to relief for a subset of people with pain that might otherwise do well. Safe opioid prescribing is the result of assessing the (known set of) vulnerabilities in these highly stressed people (as all people with chronic pain are) and accommodating the delivery of opioid therapy to them. Rather than blame the drugs, we should ask why we have not been able to incorporate this simple axiom into pain management.  

I shared an early version of a talk I will be giving during the upcoming Pain Week, in which I made the above argument, and a colleague said to me, "I didn’t realize you were so pro-opioid."

My response: "I'm not pro opioid. I am anti-BS."

We are now living in a moment when, as my colleague’s comment showed me, even people who have been critical of overuse of opioids or balanced about them can be considered pro-painkiller. And we are coming out of a period when arguing for a balanced approach made you seem like a party pooper. I have patients who have been seeing the same doctors for years only to have these doctors refusing to write them a prescription. We’re not talking about unbalanced individuals with criminal histories. We’re talking about stable, low-risk people.

While advising a pharmaceutical company, I saw a statistic recently based on IMS Health data that 8.8 million people are on chronic opioid therapy and 5.5 million of them are on hydrocodone. Now, putting aside the fact that hydrocodone and other short acting opioids are not considered right for every person along the spectrum of pain and risk for addiction, could we possibly be doing things right if more than 60 some odd percent of patients are on the same drug?

Hydrocodone therapy, in patients seen once a month with no other multidimensional treatment, is good only for a very small sliver of the pain population. This is what I call minimally monitored, drug-only pain therapy. But still this is the prevailing model, and thus a very easy straw man of opioid therapy that can be knocked down with a stiff breeze. It is not a model of opioid therapy suitable for higher risk patients.

So why is this the prevailing model?

Howard Heit, Doug Gourlay, and many others have said the same thing for years. The third party payers have been a big impediment to doing it right for the patients who need more. To treat a patient as an individual with specific needs, a doctor needs to consider a range of treatment options, including psychological care, rehabilitation, physical therapy, monitoring with urine drug screens and the drugs themselves. This is a more comprehensive strategy and more likely to be met with success in higher risk patients. But it also requires more time and resources than a doctor spending a few minutes with a patient and prescribing a pill.

That’s why payers prefer pills. Yet the payers never seem to get their share of the blame for the prescription abuse epidemic that is, in part, a byproduct of the pressure of trying to do opioid management on the cheap.

Related Content:

Q&A with Cathryn Jakobson Ramin: The Billion Dollar Back Pain Industry 

Everybody Hurts: Chronic Pain Is In the Body of the Sufferer

Photo credit: Robson# via Flickr

Comments

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It is always refreshing to read of a professional in the pain care field standing up for evidence-based truth. Kudos to Dr. Passik.

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After seeing many pain patients that use hydrocodone for chronic pain it seems a poor choice when this medication wears off in just 2 hours requiring more,then more and more after that. Seems a cycle of going around in a circle never reaching the pain relief required. The more a person takes this looks like abuse,so why not take something that works with less frequency of repeated dosing. Not to mention the Acetaminophen involved, 10/500 APAP stands for 10 mgs of hydrocodone and 500 mgs of acetaminophen. After a few years that’s a strain on the liver. I don’t have to be a doctor to know this.
I'm not trying to tell people what to take or not take but think smart. What would be best to take is lesser milligrams and less times a day and get the pain relief you need with less side effects. If I could only turn back time I would have become a Pain Specialist. But just like I cant go back in time I can compare everything I read and come to the conclusion how best treat the infliction of chronic pain, doctor or not.

Regards,
Mark S. Barletta

Picture of Mark Barletta

Treating chronic pain is just not that easy.Yet treating the cause does resolve the pain, if you have a paper cut, you wash it with soap and water and cry for while. Every one with chronic pain must get a complete workup by a doctor to see if the problem can be treated or if it is a beginning of some kind of disease. But many times, the intersection of an underlying cause and pain is more complicated. Painful diseases might be chronic and hard to control. Sometimes pain lingers even after the original cause seems to have been resolved  and times the cause of pain is mysterious. People with chronic pain often need a onward approach, get treatment for the underlying cause and separately get treatment for the pain itself. That often means seeking a Pain Specialist or other experts in this field. Many people still struggle through life with chronic pain for no reason. People think that if their pain is bearable, it's not worth asking a doctor about it.You must get pain evaluated, even if it's mild. It could be the sign of underlying disease or health problem that needs treatment. Second, treating pain promptly can sometimes prevent it from turning  into severe intractable pain.

Is chronic pain a disease it its own right. Don’t answer that ,this is another discussion for another time but Chronic pain can be never ending. It sneaks up on you, worsening slowly and surely. Without realizing it, you might develop unhealthy ways of coping with it. That might include using OTC painkillers for a long time or at high doses, which can have serious risks. People with chronic pain are also at higher risk of relying on alcohol or other substances to numb their pain. Over time, chronic pain can also lead to sleep deprivation, social isolation, depression, and other problems that can affect your relationships at home and at work. Over and out,

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