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Opioids for the Treatment of Chronic Pain… Use or Abuse?

In the United States, chronic pain affects more than 100 million people – which accounts for almost a third of the population. But despite how common chronic pain is, an Institute of Medicine Report estimates that 40 to 70% of chronic pain patients do not have their pain adequately treated. In the past twenty years, increasing awareness of this issue among doctors as well as increasing demand for better pain care among patients had lead to a rise in the number of prescriptions being written for opiates (narcotics). Unfortunately, during the same time period, there has also been a three to five fold increase in overdose related deaths and injuries, as well as a rise in levels of addiction.

Because chronic pain is not unusual in patients living with rheumatoid arthritis and other types of chronic conditions, this is an important topic for rheumatologists and rheumatology health care professionals. For that reason, there was a debate held on the subject at the American College of Rheumatology’s annual meeting in San Francisco, California on November 9, 2015. The question being debated by two prominent doctors was this: can doctors safely prescribe opiates for chronic non-cancer pain?

Dr. Daniel Clauw, a Professor of Anesthesiology, Medicine (Rheumatology), and Psychiatry at the University of Michigan delivered the argument against the use of opiates for managing chronic non-cancer pain. The fist question he discussed was whether opioids are even effective in the treatment of chronic pain. While he granted that opioids work fairly well for most individuals with very acute pain, Dr. Clauw argued that there is a dearth of data regarding the effectiveness of opioids for treating chronic pain. According to available data, most opioids have only been shown to be effective in treating a single chronic pain condition. Nevertheless, due to regulatory precedent, these medications are often approved for use in any type of chronic pain. Dr. Clauw maintained that these flaws in study design and labeling have allowed pharmaceutical companies to market opiates to anyone with chronic pain, regardless of efficacy. Overall, he thinks this has done more harm than good.

The United States has roughly 4% of the world’s population, but now consumes over 80% of the world’s opioids. In 2013, more than 16,000 individuals died from overdose of prescription opiates, as compared to 7,000 who died from the illegal drug heroin. Dr. Clauw pointed out that these statistics also represent the best-case scenario, since death certificates do not always record the specific cause of “overdose.” In addition, Dr. Clauw reminded the audience that prescription opioids often serve as a gateway to heroin use, as 75% of heroin users first experience with an opioid is a prescription one. Additionally, the switch to heroin is often economically driven, as heroin can actually be cheaper to obtain.

Dr. Clauw’s conclusion was that opioids should be used as a very last option for some types of chronic non-cancer pain, but that he didn’t think doctors were being careful enough in choosing the right types of patients. He warned doctors in the audience to consider the downstream consequences every time they prescribe an opiate. Not only is there a risk that the patient may abuse the medication, there is also a problem with diversion, where the prescription opiates end up in the hands of people other than to whom they were prescribed. This is particularly problematic in cases where doctors write big prescriptions to avoid the hassle of writing multiple prescriptions. Dr. Clauw contended that this over-prescribing needs to be reigned in to protect society. He compared opiates to guns – although the police may use guns to protect us, they can also be very dangerous in the wrong hands.

Dr. John Markman, director of the Translational Pain Research Program in the Department of Neurosurgery and Professor at the University of Rochester School of Medicine, delivered the argument in favor of using opiates as an option to treat chronic non-cancer pain. Like antibiotics being used to treat a bacterial infection, he argued that opioids are nothing more that a tool that, when used properly, may be very helpful to patients living with chronic pain.

However, Dr. Markman did acknowledge that opiates are not appropriate for every patient. He encouraged the doctors in the audience to assess the risk factors for abuse and then prescribe opiates to chronic pain patients when appropriate. He pointed out that if doctors refuse to prescribe opiates outright, they may be “leaving relief on the table.” He also pointed out that most patients do not wish to take opiates or stay on them over the long term, and that many patients can be trusted to use opiates appropriately.

Overall, Dr. Markman maintained that it doesn’t really make sense for doctors to be “for” or “against” opiates. Instead, he argued it only makes sense for doctors to be “for” their patients – which means using whatever tools are available to get the best possible outcomes for patients. Dr. Markman contended that the abuse rhetoric surrounding discussions of prescription opiates can actually also be dangerous for patients, as it may keep opiates away from patients who could greatly benefit from their use.

Instead of the gun metaphor, Dr. Markman encouraged doctors to see opiates as a car. A car is a tool that can be highly beneficial, though it does also have the potential to be dangerous. However, rather than forbidding cars all together, we work to make them safer. We give only certain people permission to drive them. This is the approach Dr. Markman recommended for opiates in order to provide the best outcome for patients living with chronic pain.

This activity is not sanctioned by, nor a part of, the American College of Rheumatology.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The RheumatoidArthritis.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Comments

  • Deena
    3 years ago

    First off let me say that I am in the medical field… In my 20 yrs as such have seen that most pt that abuse/addicted to pain meds. have for the most part had back surgery that wasn’t done properly. The funny part of abuse that isn’t quite so Funny is that the lower income are, in my experience the Biggest Abusers. Not because of Addiction but because they are able to get the Opioids free or for $.50 then proceed to sell them for at least $7.00 each so if they have a prescription for 120 hydrocodone that equals $840.00, Now that Is one Heck of a Profit. Now that being said HONEST working people like myself who actually need these meds. to funtioned are unfortunately grouped in with the above mentioned so in turn it makes it Difficult to obtain the pain meds. Then you worry that your physician may think you are a Drug Seeker as we refer to them…

  • Mariah Z. Leach moderator author
    3 years ago

    Hi Deena~
    Thanks for sharing your experiences – that is an interesting point coming from someone in the medical field. It’s a complicated problem and you are right that economics play a role. Hopefully we can keep working towards a solution that has less impact on patients living with chronic conditions.
    Best,
    ~Mariah~ (Site Moderator)

  • 1o4he8d
    3 years ago

    I’ve taken a maintainance dosage of hydrocodone for 6 years. I’m not an addict, I’m a 57 year old disabled school teacher with chronic pain from RA. I literally could not function without painkillers. It provides me with a quality of life I wouldn’t have otherwise. I am angry that the so called “drug czar”, Botticelli, has decided that WE are the problem. From what I understand, he’s newly sober (under 5 years) and thinks the 12 steps of Alcoholics Anonymous is gonna work on pain. I’ve been sober since 1987 and can tell you that is RIDICULOUS. He isn’t even a physician and 41% of the doctors surveyed didn’t agree with the new draconian laws, but here we are. I challenge any one who thinks that opiates don’t work for chronic pain live in my body without them for 24 hours. I am currently quartering my painkillers so I have enough to last until I see my doctor on Monday.

  • Mariah Z. Leach moderator author
    3 years ago

    I think many of us living with chronic illness depend on pain killers to a certain extent to maintain our quality of life. It is frustrating that laws meant to halt abuse have such a negative impact on patients who are already suffering. Hang in there – I hope your doctor was able to help you come up with a solution when you saw him/her!
    ~Mariah~ (Site Moderator)

  • Jana
    3 years ago

    My Doctor was MY NEXT DOOR NEIGHBOR saw and talked to me all the time. When it came to pain meds in his office he talked to me like I was a drug addict told me I just needed to learn to live with it. I would like to see him live with it. I hate opioid meds they make me itch like mad and are constipating and keep me from sleeping. I was on morphine for a year once it was like internal combustion. Steriods also keep me from sleeping and make me feel very irritable. I’ve been on several biologic after the Dmrds. It seems there are no good pain relieving options. My experience at the latest pain management clinic was as another person posted. Pay for a copay and lab work in order to get pain meds because my rhumeatologist doesn’t prescribe opioids. Then the pharmacy doesn’t stock them as a safety precaution so you have to wait 72 hrs. How many hoops do we gave to go through because of the criminals that abuse medications those of us with chronic pain get treated like drug addicts.

  • Mariah Z. Leach moderator author
    3 years ago

    Hi Jana~
    What a difficult situation – with your doctor treating you one way as a neighbor and another as a patient! It is frustrating not to be seen as a whole person. I hope that you will be able to come up with a better solution in the future, though I agree that the hoops we have to jump through are quite frustrating!
    Best,
    ~Mariah~

  • Vicki Heckroth
    4 years ago

    I take a low dose of morphine, 30 mgs a day, and 40 mgs of oxycodone per day and that barely takes the edge off. plus I am on Orencia. I cannot tolerate methotrexate and arava made my hair fall out. Before I had my kness both replaced a year and a half ago I was on 90 mgs of morphine but because my knees should no longer hurt, which in fact they do, that was cut back. Which only meant more pain for me. But without at least having the edge taken off I don’t know how I would manage. I also take several other meds and am on oxygen at night due to RA nodules in my lungs. People who say we don’t need the opiates or narcotics or any of our meds have never suffered the daily excruciating pain that we have.

  • Mariah Z. Leach moderator author
    4 years ago

    Thanks for sharing your story, Vicki. I do hope you will continue to have options to manage your pain.

    Best,
    ~Mariah~ (Site Moderator)

  • RHPass
    4 years ago

    in order to get my pain meds renewed I had to sign a 4 page contract with my doctor. when I finished reading it i was in tears! i felt like a criminal. i had to give my doctor the right to have me ARRESTED if I got or tried to get pain meds from any other doctor. also if I gave one pill to anyone else to help them out (not just a family member either). the prescription was bare minimum and barely keeps my pain bearable.I am fully aware that a certain level of adddiction plays into this, but all I want to do is get through one day at a time without debilitating pain. random drug testing to be sure I AM taking my meds & not selling them is also a part of it. it is bad enough being in pain 24/7/365 and not being able to walk enough to take care off my own self, but adding the guilt and being treated like a ‘crack head’ or street dealer is even worse! just because the government can’t handle the addicts & dealers makes life hell for chronic pain sufferers.

  • Mariah Z. Leach moderator author
    4 years ago

    Hi RH Pass~
    It is so frustrating that attempts to deal with abuse have such a negative impact on people who actually benefit from these medications. It really seems like there must be a better way than to allocate additional burdens to people living with chronic conditions!
    ~Mariah~ (Site Moderator)

  • SofiaRA
    4 years ago

    I am so concerned as a patient with Rheumatoid Arthritis,and pseudogout,that there will come a time that we will no longer be able to have proper pain meds prescribed to keep our pain under control. My RA biologic does not keep me from having pain. I think once we have a certain amount of damage done to our joints that is not reversible. I also cannot tolerate methatrexate, so I cannot take it with my biologic. That leaves me with taking low doses of prednisone, or a low dose opioid for additional pain control. The doctors don’t want you to take low dose prednisone for very long because of long term side effects, and I agree I hate the side effects too but sometimes you have to take it. The only other option I have is pain medication. I worry that if this is taken away as an option for treatment I will become even more disabled than I am. I will become more depressed and immobile. That downward spiral leaves you with no hope in the end of being able to function on a daily basis.

  • Mariah Z. Leach moderator author
    4 years ago

    Hi SofiaRA ~

    I certainly understand your concern as I share it myself. As Dr. Markman said, it seems like these medications ought to remain a tool in the doctor’s arsenal for patients – like yourself – who have trouble with other medication options. Luckily even Dr. Clauw didn’t recommend taking pain medications away from patients who already use them. Instead, he seemed to be advocating for not prescribing them to additional patients – though I have some concerns that would leave relief on the table for newly diagnosed individuals!
    ~Mariah~ (Site Moderator)

  • Pain day and night
    4 years ago

    I’m not sure if Dr. Daniel Clauw has RA, but if he does, I can’t believe he is against opioids for the intense and endless pain caused by RA in most people that have it. If he doesn’t, that explains why he does not believe in using opioids for moderate to severe RA. I take opiates for my severe RA and even though they don’t take the pain away completely, they do take the edge off the pain and make it more comfortable to just do every day living. If I didn’t have them, I think I would probably be considering doing away with myself because I am in so much pain all over my whole body all day long. I am at my worst for a couple of hours after I wake up in the morning, or if I sit in a chair for a while or a car, or if I do any kind of the lightest amount of manual labor and I can’t walk, even with a cane that I have to use, more than about 50 yards before the pain starts in my legs, hips, knees, ankles, feet and especially my toes. I also can’t drive on highways for more than about 10 miles because if I just keep driving with my foot on the gas for a long period of time without being able to move the leg..which then starts to spasm in my calves and thighs and pain in my lower back, so it is dangerous for me to do so. I even have so much pain that it wakes me up from my sleep ever single night. The pain is a hell I could never had imagined living with before I had RA. I have been taking one drug for ten years and have not asked for a higher dose until 3 months ago because I know if one keeps raising their dosage, eventually none of it will work so you just have to use your will power to stay with the same dose you have for a very long time if you want to keep being able to get some relief from the pain that I am in. It just so happens that at 3 am today, I had to get out of bed and read because I had such terrible pain in one of my arms that it made sleeping impossible. I have also been on a biologic for about 8 years and not 10 because I wanted to try everything else first before I went with the biologics, which can have terrible side effects, but worth the chance to take because it slows down the progression of the disease and hopefully keeps one out of a wheel chair for as long as possible, if not forever…but they don’t do anything for the pain for me. So, Dr. Daniel Clauw, if you don’t have RA, I wish that there was a way for you to experience life with RA and the pain and problems that go with it for about a month before you declare that you won’t prescribe the opioids to patients with a bad stage of RA.

  • carhastings
    4 years ago

    This article couldn’t be more timely. Not only are we at the mercy of doctors who have no idea how debilitating severe chronic pain is, but now the government & insurance companies are involved. We paid $12,700 for insurance & medical last year. Our Insurance doesn’t cover “alternative” therapies like Tai Chi, Yoga, Acupuncture, etc. so that would be more out of pocket.
    Our insurance recently instituted a policy that you can only get your opiates renewed 2 days before your last prescription will run out. I realize this is to curb abuse, but this insurance is located in the same state I live in…where outside of the major cities, we are likely to get literally snowed in for several days per month!
    My Dr. requires 48 hr advance for prescription refills, our pharmacy doesn’t order them until the scipt is in hand (to keep from getting robbed), AND they aren’t open Sundays. It’s ridiculous to have to deal with a Dr, pharmacy, and SNOW within a 2 day window to get “some” relief. (They only prescribe enough to take the edge off of the pain, never totally relieve it.)
    We are also rural, which means the Dr/pharm are a 1.5 hr round trip in good weather. This trip needs to be made twice in two days: once to get the script & drop it at the pharmacy, once to pick it up the next day. All of this while I’m in sometimes horrific pain, and praying that the weather cooperates. THIS type of nonsense is likely the cause of the abuse and suicides!
    Treat us like HUMANS, and kindly and adequately treat the disease we never wanted, or caused. Is that too much to ask?

  • Pain day and night
    4 years ago

    Carhastings, I feel for you and know exactly what you are going through. It shouldn’t be this way for people who have certain diseases that absolutely need pain medication and it is this way because there are some people out there who steal their mom’s or friends drugs to get high with and some of them become addicted. We shouldn’t be penalized for their criminal behavior. Best of luck to you!

  • Mariah Z. Leach moderator author
    4 years ago

    Hi Carhastings~

    I certainly understand the frustration you are experiencing – we’ve spent a similar amount on medical this year and the year isn’t even over yet! I have to go through a similar process to get my hydrocodone prescription, and I’m usually hauling two kids in and out of the car every step of the way! (I shared in more detail about my experiences in this article: https://rheumatoidarthritis.net/living/must-better-way/) I really wish that regulations could be less burdensome on patients with chronic illness who often rely on these medications to function on our worst days!

    ~Mariah~

  • janlorraine
    4 years ago

    I know that this is a controversial issue and that new government regulations have made the prescribing of opiates for chronic use very difficult. Those of us who need these medicines on a regular basis are all suffering because some people choose to abuse them. This is unfortunate and I wish that the situation was different. Not long ago my rheumatologist told me that if I wished to keep receiving this drug I must go to a pain management clinic. While I appreciate the fact that I am still able to receive a prescription for hydrocodone, I can’t help but feel that pain management clinics are a bit of a racket. I have to go every four weeks, I never know if I will have a urine test to make certain I am in compliance with my contract and that I am taking the drug and not selling it on the street and, of course, I am charged my co-pay. All I go for is a new prescription; there is nothing else they do for me except ask me my pain level. I find the entire rigmarole very depressing, but I can’t imagine what my life would be like without the pain relief I get from hydrocodone so I keep going and don’t complain.

  • Mariah Z. Leach moderator author
    4 years ago

    Hi Janlorraine~

    I also understand the need for regulating these substances, but I too wish that these regulations could be less burdensome for chronic illness patients. We already have enough burdens to be getting along with! Hopefully there will be improvements in the future!

    ~Mariah~

  • Wren moderator
    4 years ago

    Thanks for writing such a clear, interesting, and important article, Mariah. This is a discussion we must have.

    I’m always puzzled by statements like Dr. Clauw’s regarding no data on how well opioids work on chronic pain. In fact, there have been almost no studies at all, and those that have been done were very small or not terribly credible. In addition, the statistics Dr. Clauw uses about overdoses and deaths don’t take into account other factors besides opioid use, such as how many of the number were actually long-term chronic pain patients, whether there was a history of abuse, the other medications taken concurrently by each, the underlying disease causing the pain in each, age and mental status, etc.

    I’m all for safe, monitored prescribing practices and for manufacturing these drugs in ways that make them more difficult to abuse. I’m also all for incorporating other pain management tools, like acupuncture, cognitive behavioral therapy, tai chi, etc. in tandem with narcotic pain relievers with an aim to decrease dependence. But to simply stop the use of opioid analgesics in chronic pain patients without credible research–or because there is none!–is to cruelly sentence them to a lifetime of unremitting, unrelieved pain–and potentially cause not only new heroine addicts as they try, desperately, to find alternatives to relieve their pain, but also suicides when the pain simply, finally overwhelms them.

    Like the other commenters here, I wish Dr. Clauw and his like-minded colleagues could live with the pain RD patients live with daily for, say, a year. Let him discover the good opioids can do over a long period (6 months), then take them away and encourage him to try yoga and positive self-talk to learn to live with and endure his pain instead. My bet is he’d sing a different tune long before that year ended. In fact, I think he’d change sides entirely.

  • Mariah Z. Leach moderator author
    4 years ago

    Hi Wren ~

    During the Q&A section of the debate Dr. Clauw clarified that he wasn’t advocating for stopping the use of opiates in chronic pain patients who are already safely using them as part of their treatment – but rather he emphasized the need to stop providing new prescriptions for these medications, though I’m not honestly sure that is any better, as newly diagnosed chronic disease patients could potentially benefit from opiates as much as long-diagnosed ones. I did think Dr. Clauw made a fairly good point about doctors being to blame for some of these issues – by trying to reduce their workloads rather than carefully evaluating patients needs on a regular basis. In any event, it was certainly an interesting event to attend!

    ~Mariah~

  • Linda
    4 years ago

    Every doctor that comes out against opioids for non cancer pain does not have non cancer pain so how can they know? The meds do not help my Fibro, no, but they are a God send for my RA pain. I do not get high from them, I get sleepy and nauseous. I wouldn’t take them if I did not need the relief. I already have had to double the times I see the doctor per year, costing me time and money. I have to jump through all sorts of hoops to get a prescription filled. Unless you have a viable option for cronic pain stop trying to take away what allows me as much of a normal life as I can manage to live. I wish these doctors 48 hours of what we have to live with, then let them rethink their position.

  • Mariah Z. Leach moderator author
    4 years ago

    Hi Linda ~

    I certainly understand some of the frustration you describe. I personally find it frustration that regulations aimed at reducing abuse often put such a burden on chronic illness patients – who already have enough burdens! The good news is that there doctors like Dr. Markman who believe opiates are a valid treatment option!

    ~Mariah~

  • jcoco67
    4 years ago

    I looked up Dr. Clauw’s credentials and he should never have been included in this article. He deals mostly with Fibromyalgia patients – where the chronic pain, as he states in his address to congress, “is coming from the brain”. RA pain is not nerve pain – it’s the actual feeling of your joints deteriorating. I’m not saying Fibro isn’t painful and I absolutely believe it to be real and terrible but Dr. Clauw needs to realize that these are two totally different diseases and as such, need to be treated differently!

  • Mariah Z. Leach moderator author
    4 years ago

    Hi JB67 ~

    I included Dr. Clauw’s argument in this article as he is the person the American College of Rheumatology had selected to present the “con” side of the argument during the debate at their annual meeting. He did spend a fair amount of time at the event discussing fibromyalgia-type pain, which certainly influenced his argument.

    Regards,
    ~Mariah~

  • Jonathan Hunter
    4 years ago

    I am puzzled by Dr. Clauw’s argument..Opiates work well for acute pain but no evidence of benefit for chronic pain? Color me stupid, but is chronic pain not simply acute pain OVER TIME?

    Perhaps Dr Clauw would like to wake up into pain every day, lose his job and his friends due to pain and then academically pontificate about one of the few chemical compositions that may offer him relief. Until such time he has no veracity in my world..simply another bloviating “expert” eating up precious bandwidth.

  • Mariah Z. Leach moderator author
    4 years ago

    Hi Jonathan ~

    I certainly understand the frustration you feel in regards to Dr. Clauw’s argument – I felt a similar frustration myself as I listened to him make it at the American College of Rheumatology’s annual meeting. I think Dr. Clauw was particularly concerned with the issues of abuse of opiates, but I agree that there must be a better way to deal with those issues than to take treatment options away from patients who might really benefit.

    ~Mariah~

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