Balance, Pain

“The conundrum of Opioids” … from the IOM Report; Relieving Pain in America



The Institute of Medicine’s Committee on Advancing Pain Research, Care, and Education released  its report “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research” today.

The committee, shares with us that at least 116 million US adults are burdened by chronic pain resulting in an estimated annual national economic cost of $560-635 billion.  A brief report is available at http://ht.ly/5t7MT.

The committee, chaired by the Dean of Stanford University School of Medicine, Professor Philip Pizzo, MD  comes to one basic conclusion.

“Pain affects the lives of more than a hundred million Americans, making its control of enormous value to individuals and society. To reduce the impact of pain and the resultant suffering will require a transformation in how pain is perceived and judged both by people with pain and by the health care providers who help care for them. The overarching goal of this transformation should be gaining a better understanding of pain of all types and improving efforts to prevent, assess, and treat pain.”

They used  several important underlying principle to inform their charge:  To provide a blueprint for transforming the way pain is understood, assessed, treated and prevented.

  • A moral imperative
  • Chronic pain can be a disease in itself
  • Value of comprehensive treatment
  • Need for interdisciplinary approaches
  • Importance of prevention
  • Wider use of existing knowledge.
  • The conundrum of opioids
  • Roles for patients and clinicians
  • Value of a public health and community-based approach.

To highlight “The conundrum of opioids” as an underlying principle the following detail is provided:

The committee recognizes the serious problem of diversion and abuse of opioid drugs, as well as questions about their usefulness long-term, but believes that when opioids are used as prescribed and appropriately monitored, they can be safe and effective, especially for acute, post-operative, and procedural pain, as well as for patients near the end of life who desire more pain relief.

We have discussed a number of recent reports that highlight barriers including the JAMA report by Volkow and McLellan (JAMA 305; 13) and the committee confirms that significant barriers to adequate pain care exist (Finding 3.2) and in particular

Regulatory, legal, educational and cultural barriers inhibit the medically appropriate use of opioid analgesics.

And they go on to make Recommendation 3.2.  “Develop strategies for reducing barriers to pain care.”

The population-level strategy referred to in Recommendation 2-2 should include identifying and developing comprehensive approaches to overcoming existing barriers to pain care, especially for populations that are disproportionately affected by and undertreated for pain. Strategies also should focus on ways to improve pain care for these groups.

So a public health approach for the management of pain is recommended, one that is not only addressing the educational and research challenges for the future but one that addresses the ongoing care of those with pain. Opioids are part of this ongoing care and will need to be addressed in a balanced manner, an approach that has long been supported by the PPSG.

It is another reason to ensure that the issue of opioid access is addressed at the UN meeting on Non-Communicable Diseases.  It is a problem not just for the USA but for the world.

jfc

About Pain policy & palliative care

Improving global pain relief by achieving balanced access to opioids worldwide

Discussion

8 thoughts on ““The conundrum of Opioids” … from the IOM Report; Relieving Pain in America

  1. This report offers little for people in pain to hope for-they indicate they dont believe pain can be cured, they indicate that the prevalence of pain will rise. Furthermore, they label people in chronic pain “catastrophizers”. THe IOM failed to mention the biggest barrier to improving pain care is the lack of will of the health care industry. And as this report doesnt call for a higher standard in pain care or results oriented pain care- or for anyone in pain to have a right to adequate pain care- this report is much ado about nothing

    Posted by David Becker | July 7, 2011, 12:31 PM
    • David,
      Thanks for your comments.
      While it may not say enough for a higher standard or results oriented pain care, I think that the Institute of Medicine report creates an opportunity for change. THe call for more research is an important one, that may fall of deaf ears in the current Federal environment. Labeling people is never helpful.

      Posted by Jim Cleary | July 8, 2011, 8:36 AM
  2. Here’s another passage in the IOM report worth highlighting:

    “The long-term effects and effectiveness of opioid therapy are far from certain (Noble et al.,
    2008), and opioid therapy lasting longer than 90 days is characterized by diversity in the
    prescribed medications, dosages, and frequency of use (Von Korff et al., 2008). Some patients
    taking opioids on a long-term basis develop greater sensitivity to painful stimuli, a condition
    known as opioid-induced hyperalgesia (Chu et al., 2008). Changes in the functioning of sex
    hormones and the immune system also have been caused by long-term opioid use. Further,
    opioid use has been found to cause changes in gray matter that are not reversed an average of 4.77 months after cessation of use (Younger et al., in press).

    Posted by Andrew Kolodny | July 20, 2011, 6:14 PM
  3. Andrew, Good passage to highlight.
    One of our colleagues, for whom English is not their primary language, wrote to ask me to define “conundrum” for them.
    From the dictionary: 1. A confusing and difficult problem or question.
    The paragraph you are highlighting adds to the issues that contribute to conundrum.
    The committee has been very careful as I highlighted in their language.
    “….appropriately monitored, they can be safe and effective, especially for acute, post-operative, and procedural pain, as well as for patients near the end of life who desire more pain relief.”
    THis issue of opioids for pain is a confusing and difficult problem for which we need to ensure a “balanced” approach.
    jim

    Posted by Pain policy & palliative care | July 20, 2011, 9:59 PM
  4. Thanks Jim. But I must confess that I find the PPSG concept of “balance” to be misleading and harmful.

    My concern is that the PPSG tells policy makers that opioid prescribing regulations must be “balanced” to avoid limiting access to effective treatment for tens of millions of chronic pain patients.

    This is misleading because it suggests that opioids are an effective treatment for chronic pain when in fact, as the IOM report acknowledged, effectiveness of opioids for chronic pain is “far from certain.”

    So instead of implementing effective regulations on prescribing to control the worst drug epidemic in U.S. history, policy makers that buy into the concept of “balance” tread lightly for fear of jeopardizing access to a treatment that is harming more pain patients than it helps.

    Posted by Andrew Kolodny | July 20, 2011, 10:57 PM
  5. Andrew,
    Again thanks for you input. I am very keen to hear your point of view, just as I see myself as a being a responsible prescriber of opioids (the only one at PPSG who ever does this). In general we, as a group, do not make recommendations as to what is effective pain treatment. We do participate in panels that may make those decisions, primarily addressing access and availability issues, as we do on panels that define “balance”, including the recent WHO Guidelines “Ensuring Balance in National Policies on Controlled Substances, Guidance for Availability and Accessibility of Controlled Medicines. “http://www.painpolicy.wisc.edu/publicat/00whoabi/00whoabi.htm” (March 2011). So this is not just a PPSG concept, although the 2000 guidelines, “Achieving Balance” did originate out of PPSG.

    Can you give me some examples where PPSG has directed policy makers to “avoid limiting access to effective treatment for tens of millions of chronic pain patients?” I can then spend time on a thoughtful reply and in fact may devote a blog to this issue of balance from a PPSG perspective.
    Cheers.
    jim

    Posted by Pain policy & palliative care | July 20, 2011, 11:52 PM
    • Jim,

      Your willingness to engage in this dialogue is greatly appreciated as is your request for a specific example. As the new director, I think this bodes well for the PPSG under your leadership.

      Pasted below is a link to a document on your website that refers to chronic pain treatment with opioids as “safe and effective”.

      http://www.painpolicy.wisc.edu/publicat/03jlme/jlme_model.pdf

      I hope you will agree with me that this statement is false, dangerously misleading and at odds with the IOM report’s comment that effectiveness of opioids for chronic pain is “far from certain.” I hope you will also consider removing this document from your website because it misinforms readers about the actual risks and benefits of treating chronic pain with opioids.

      This article describes the “prinicpal of balance” in the following way:

      “governmental policy should be aimed at preventing abuse of narcotic drugs, but also at ensuring availability of opioids, which are essential for pain relief; efforts to prevent drug abuse should not interfere in the legitimate medical use of opioids for patient care.”

      In applying the principal, the authors determine that state medical boards with a “last resort policy” for opioid prescribing are unbalanced.

      If the effectiveness of a treatment is far from certain and it carries very serious risks why shouldn’t it be reserved as a last resort?

      Posted by Andrew Kolodny | July 21, 2011, 11:21 AM
  6. Andrew,
    I am going to spend some time addressing the issues that you have raised and will post a blog on balance on Monday.
    But regarding the document to which you refer, let me give the complete opening paragraph of the paper that you link, “Improving State Medical Board Policies: influence of a Model Law” so that we can all see the statement in its entirety.
    Back with some thoughts Monday.

    “Despite advances in medical knowledge regarding pain management, pain continues to be significantly under treated in the United States. There are many drug and nondrug treatments, but the use of controlled substances, particularly the opioid analgesics, is universally accepted for the treatment of pain from cancer. Although opioid analgesics are safe and effective in treating chronic pain, there is continued research and discussion about patient selection and long-term effects. A number of barriers in the health care and drug regulatory systems account for the gap between what is known about pain management and what is practiced. Among the barriers are physicians’ fears of being disciplined by state regulatory boards for inappropriate prescribing.”

    Posted by Pain policy & palliative care | July 21, 2011, 4:13 PM

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