The Opioid Epidemic and the State of Pain Management

Opioids and opioid policies have received increased attention over the last year in light of the “opioid epidemic.”  Opioid overdoses and deaths have reached staggering numbers and have led to a prevailing belief that opioids and people that use opioids are “bad.”  This perspective has unfortunately been a distraction from a crucial problem: poor and ineffective pain management.  Yes, addressing opioid abuse and providing addiction treatment is important, and if we do not also emphasize the importance of providing patients with early access to effective pain management, we are essentially just putting a bandage on a wound that will continue to bleed.

We recently published an editorial in Pain Management[1] (free to download and read) that discusses the current state of chronic pain management in the context of the opioid epidemic and outlines recommendations for policy development.  In this editorial, we focused on pediatric chronic pain management, as it is often absent from the media and policy proposals despite its prevalence, economic impact, and relevance to the current opioid epidemic.

Children do have chronic pain. Unfortunately, this pain is not well treated, which increases the likelihood that these children will become adults with chronic pain.  In fact, studies estimate that 5-38% of children and adolescents suffer from chronic pain[2-4] and up to 73% of these children may continue to have pain in adulthood.[5,6]  Data from the United States estimate that the economic cost of pediatric chronic pain is 19.5 billion dollars annually[7] and accounts for 11.8 billion dollars in total health care expenditures paid by insurance companies and families, an amount greater than expenditures for obesity and asthma combined.[8]

In our editorial, we presented an argument for how this significant problem developed. Collectively, the healthcare industry’s attachment to the biomedical approach (i.e. to focus on and treat physical processes that affect health, such as the physiology and pathology of an illness) has resulted in a limited understanding of the complex, biopsychosocial nature of pain and how to treat it.  This simplistic model has increased the likelihood of potentially harmful treatment (e.g. continuously refilling opioid prescriptions with no indication of improved pain or functioning).[9]  Complicating factors when treating pain are that a single medical test cannot confirm the amount of pain a child or individual is experiencing, and pain can persist when there is no identifiable damage. These issues present a problem for providers working within a biomedical framework.  Pain is experienced and maintained through complex mechanisms including biological, psychological, and social factors that all alter our pain experience.[10,11]  This is why relying on or focusing on one type of medication will not resolve the problem.  But, healthcare providers do not receive adequate training in pain management.[9]  In a United States medical school survey, only four schools had a pain course requirement and only one of those schools included pediatric pain management in the curriculum.[12]  The cumulative number of pain teaching hours across schools ranged from 1-31 hours. So, depending on how long it takes you to read this post and whether or not you review the articles cited, you may now have more knowledge about pediatric pain than most physicians.

So, where do we go from here? Perpetuating the message that opioids and opioid users are “bad” without offering an alternative or understanding which treatments are indicated for a particular pain condition does not help individuals in pain nor does it help healthcare providers better understand how to relieve their patients’ suffering.  Healthcare providers and policy makers need to receive education surrounding the proper use of opioids and the importance of incorporating biopsychosocial assessment, education and treatment in pain management.  Yes, opioids are initially cheaper.  But we argue that the costs associated with untreated pain are large.  A consequence of undertreated pain is that many patients may turn to dangerous means to relieve their pain and suffering.  Thus, inadequate pain management will continue to have a significant negative economic and societal impact.  Although there is growing evidence to support a biopsychosocial approach to pain management, uncertainty remains and more research is needed to determine how to best match patients to the most optimal treatment. This is especially true for pediatric pain management as evidence is even more limited in pediatrics and the treatment of pain in a developing child may pose unique challenges. Funding and policy proposals should prioritize the development of effective and accessible evidence-based pain treatment and best practice guidelines for adult and pediatric populations. Additionally, there needs to be increased chronic pain education and training initiatives.  Only then will the “opioid epidemic” be adequately addressed.

About Sarah Martin

Sarah is a postdoctoral fellow in the Pediatric Pain and Palliative Care Program at the University of California, Los Angeles. The work described above was conducted with Sarah’s postdoc supervisor, Dr. Lonnie Zeltzer. Sarah received her PhD in Clinical Psychology from Georgia State University under the mentorship of Dr. Lindsey Cohen. Broadly, Sarah’s research interests include the examination of individual and social-cultural factors that influence pain experiences in children with chronic or disease-related pain. Her current work – funded by the National Institutes of Health Heart Lung and Blood Institute – examines the effects of hypnosis and social factors (stigma and loneliness) on physiological pain responses in teens with sickle cell disease. Sarah was also an international trainee member of Pain in Child Health: A Strategic Research Training Initiative of CIHR. When not in the lab or clinic, Sarah can be found at the beach, snowboarding, travelling, or running with (or after) her very energetic dog.

References

[1] Martin SR, Zeltzer LK. Prioritizing pediatric chronic pain and comprehensive pain treatment in the context of the opioid epidemic. Pain Manag. 2018;8(2):67-70. Open Access

[2] Huguet A, Miró J. The severity of chronic pediatric pain: an epidemiological study. J Pain. 2008;9(3):226–236.

[3] King S, Chambers CT, Huguet A, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain. 2011;152(12):2729–2738.

[4] Perquin CW, Hazebroek-Kampschreur AAJ., Hunfeld JA., et al. Pain in children and adolescents: a common experience. Pain. 2000;87(1):51–58.

[5] Walker LS, Dengler-Crish CM, Rippel S, Bruehl S. Functional abdominal pain in childhood and adolescence increases risk for chronic pain in adulthood. Pain. 2010;150(3):568–572.

[6] Brna P, Dooley J, Gordon K, Dewan T. The prognosis of childhood headache: a 20-year follow-up. Arch Pediatr Adolesc Med. 2005;159(12):1157–1160.

[7] Groenewald CB, Essner BS, Wright D, Fesinmeyer MD, Palermo TM. The economic costs of chronic pain among a cohort of treatment-seeking adolescents in the United States. J Pain. 2014;15(9):925–933.

[8] Groenewald CB, Wright DR, Palermo TM. Health care expenditures associated with pediatric pain-related conditions in the United States. Pain. 2015;156(5):951.

[9] Relieving Pain in America : A Blueprint for Transforming Prevention, Care, Education, and Research / Committee on Advancing Pain Research, Care, and Education, Board on Health Sciences Policy, Institute of Medicine of the National Academies. Washington, D.C. : National Academies Press, c2011.; 2011.

[10] Simons L, Elman I, Borsook D. Psychological Processing in Chronic Pain: A Neural Systems Approach. Neurosci Biobehav Rev. 2014;0:61-78. doi:10.1016/j.neubiorev.2013.12.006

[11] Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. J Pain. 2015;16(9):807–813.

[12] Mezei L, Murinson BB. Pain Education in North American Medical Schools. J Pain. 2011;12(12):1199-1208. doi:10.1016/j.jpain.2011.06.006