Monday, November 19, 2012

Opioids for Chronic Pain: Modern-Day Bloodletting

I came across an amazing piece today written by Malcolm Butler, MD, Medical Director at Columbia Valley Community Health Services in Washington State.  This should be required reading for all of us doing battle in the trenches of the opioid epidemic. 

A link to the full piece is here.  In summary, Dr. Butler confronted the central challenge of his clinic by taking proactive steps to eliminate medically inappropriate opioid prescriptions from his practice.  He sums up the results of the initiative as follows:

"Here is what we have learned:
  1. After 15 years of trying to follow published standards of high quality pain management,
    1. There is NO evidence that opioids improve outcomes in chronic pain.
    2. There is good evidence that opioids impair social function, contribute to behavioral comorbidities, and decrease function.
    3. Opioids are excellent for acute pain but are just the wrong tool for chronic pain.
    4. It makes about as much sense to treat chronic pain with alcohol as with opioids. Both will help pain in the short run. Both will cause new and more difficult challenges in the long run.
  2. By asking every patient about pain at every visit, we had “medicalized” pain.
    1. Pain is a normal component of everyday life – it is not an anomaly requiring treatment.
    2. Pain is a protective reflex. It galvanizes us to improve and change. Removing it does the opposite, allowing us to become victims and to stagnate.
  3. As we have weaned our patients down on their opioids – nothing has changed. The patients who were working while taking 400mg a day are still working when taking 100mg a day. Those who were lying on the couch while taking 400mg a day are still lying on the couch while taking 100mg a day.
    1. There appears to be a dose above which more opioids don’t improve function in chronic pain – and it must be pretty low, as we still haven’t found it.
    2. As we have decreased the volumes of opioids we prescribe, bad behavior of all types has decreased within the clinic. Whereas the OOC used to review 6 cases per month, we now review 2 cases every 3 months.
  4. Chronic pain is a mélange of nociceptive pain, emotional pain, boredom, and anhedonia – all of which feel better on opioids, and all but one of which are made worse by chronic opioids.
      1. Acute pain is almost entirely nociceptive pain, and is well managed with opioids.
      2. Chronic pain is amplified and prolonged by the use of opioids."
This is what it takes.  Courage, transparency, honesty... and the ability to say NO.
On Twitter @PRIUM1


  1. If opiods are not the answer to chronic pain, then could you please explain the solution?

    1. I'm not a physician, but I work with physicians every day on both sides of this public health issue. I want to be clear that I believe (as do most physicians) that there are limited circumstances under which long term opioid therapy may be appropriate for treatment of chronic pain. These cases, however, are the exception - a tiny minority of injuries amongst a plethora of over-treatment, dependence, and addiction. In the vast majority of cases, long term opioid therapy fails to relieve pain (in fact, it often leads to increased pain). Often, the emotional distress and chemical dependency (i.e., the underlying cause of the pain) isn't adequately addressed. Treatment of chronic pain needs to start by addressing these fundamental clinical issues. This can be accomplished through tools such as cognitive behavioral therapy, functional restoration, and comprehensive multi-modal pain management programs.

    2. I'm not a doctor either, but I know of people who, when they were prescribed opiods, were able to fuction at a higher level and suffer much less. Often, options like surgery are of little or no help, with one leading to others limiting mobility and not limiting pain. While I'm sure there may have been overprescribing at times, I also think it's easy to discount pain when it is not yours and discuss options like comprehensive muli-modal pain management programs which have been tried and failed to offer relief.

    3. Beware of the opioid anecdote. True, there are cases of increased functionality over the long term, but the data tells us chronic opioid therapy carries more risk than reward.

  2. This is the smartest thing I have read for a long time. Chronic is multifactorial and biopysychosocial in origin. A very difficult and complex problem to fix, but opioids are just a quick but dangerous bandaid solution. I have yet to see a patient on opioids who really benefits in the long term.

  3. Well I can tell not one of you have ever lived day to day with constant pain. The kind of pain that drives you out of your mind with thoughts of is it worth living like this. Well I have and do live with that kind of pain. If it weren't for the pain patch I wear I wouldn't be here right now because I would have decided enough is enough and taken my own life!

    And many people do take their own lives who can't get the help they need because doctors are so afraid to prescribe opioids. But there is one thing that is the most important issue besides the opioids and that's a doctor who cares enough to work with a patient to find out what works for that patient. Not all chronic pain patients are the same and can't be treated that way because if you do treat them the same that's where you run into problems.

    I have been on my present pain patches for over 2 yrs after going through 8 yrs of pure agony because I was not given the correct meds. In those 8 yrs I had so many surgeries that weren't necessary all due to the fact the doctors didn't want or were afraid to prescribe the correct pain medications or just didn't want to be bothered to take the time to listen.

    I also do a multiple level regime.

    You state that long term use of opioids can lead to increased pain. I have to disagree with you there due to the fact I have been on the correct pain meds. for 2 yrs and have had an almost normal life. Where as before I couldn't function at all. You will notice I said "correct" pain medication. It's that simple.

    We could go back and forth on this issue. But I believe that it takes a doctor who takes his time with a chronic pain patient and cares enough to help that patient.

    Sincerely yours,
    A retired nurse