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Integrative Healthcare Symposium 2017
The Integrative Healthcare Symposium, an annual meeting of multidisciplinary practitioners of functional and integrative medicine, was held February 23–25 in New York. Reviewed below is a presentation by an anesthesiologist who has staked out a controversial position against routine use of opioids for chronic pain.
Managing Chronic Pain: The Age Before and After Opioids
Lessons drawn from the epidemic of opioid addiction include strong recommendations against opioid use for chronic pain, according to Dr. Ballantyne, who spoke during a panel discussion entitled “Pain, Prejudice, and Opioids: Emerging Policy and Integrative Practice.”
“Use of opioids for chronic pain misunderstands chronic pain. If we can teach people to live well with chronic pain and provide them with the right tools, that is the best we can do,” she said. “The overprescribing of opioids in the 1990s and 2000s produced the worst iatrogenic catastrophe ever … Opioids have a very limited role in the treatment of chronic pain because they carry enormous risk and have not been shown to be beneficial if used continuously long term.”
Dr. Ballantyne’s opposition to the routine use of opioids in chronic pain, especially the use of pain intensity scales as absolute guides to opioid prescribing, has roots in the work of H. K. Beecher, who identified as a fundamental error the notion that experienced pain correlates exactly with the amount of nerve-ending stimulation.12 She cited Wilbert Evans Fordyce (1923–2009), who developed the idea of operant conditioning as a factor in chronic pain and who championed cognitive behavioral therapy strategies and behavioral principles for encouraging patients to become active again and to cut back on pain medication. The roots of pain, both Beecher and Fordyce theorized, are created by past experiences and may not be found in the body or explained by pathology.
Centers for Disease Control and Prevention figures reviewed by Dr. Ballantyne correlated the dramatic increase in opioid sales and overdose deaths with treatment between 1999 and 2010. Data from the Drug Abuse Warning Network show that, for every U.S. opioid overdose death in 2009 (n = 15,597), there were nine treatment-abuse admissions, 30 emergency department visits for misuse or abuse, 118 people with abuse/dependence issues, and 795 nonmedical users of opioids. Behind the dramatic increases, she explained, were the palliative care physician and pharmaceutical industry promotion of opioids for chronic pain, U.S. health care system factors, and U.S. cultural factors. The industry-funded “educational” messages at work, according to Dr. Ballantyne, were:
- Physicians are allowing patients to suffer needlessly because of “opiophobia.”
- Opioid addiction is rare in pain patients.
- Opioids can be discontinued easily.
- Opioids are safe and effective in chronic pain.
- Palliative care principles (such as titration-to-effect) apply equally to chronic pain.13–16
What’s wrong with long-term continuous opioid use, Dr. Ballantyne said, is that it is based on a misunderstanding of chronic pain, specifically because suffering is related less to pain intensity than it is to meaning, disability, role, function, attitude, and expectation—all of which can be changed. Physiologically, she added, opioid use “commandeers the endogenous opioid system,” leading to neuroadaptations linked to tolerance and dependence. “Giving exogenous opioids overwhelms these natural systems and prevents the protective defensive mechanisms from taking place … Isolation, withdrawal, distress, family, job, culture, all influence the development of chronic pain and are indicators of derangement in natural opioid systems,” she said.
The rate at which susceptible individuals will become addicted is fairly constant at 12% to 20%, with close correlation between the opioid amount and addiction. Activity and exercise, which are therapeutic for many pain conditions (especially musculoskeletal pain), are suppressed by opioid use.
Dr. Ballantyne pointed out that the evidence from modern imaging, which enables viewing of most pathological causes of pain, shows that two individuals with the same pathology on an image may experience pain very differently. Pain may become the focus of a life of suffering in one, while for another, the physical pain is sublimated or even disappears.
“The overuse of opioids for chronic pain is a distinctly U.S. problem,” Dr. Ballantyne said. For 90% of chronic pain, opioids have not proven helpful, she said, mentioning specifically axial low-back pain without a pathoanatomical diagnosis, fibromyalgia, and headache.17 “What is the U.S. going to do about it?” she asked, urging what amounts to a “cultural transformation,” including the “demedicalization of the most common pain conditions.” For example, when a patient presents with back pain, she said, the old pathway would begin with investigation through imaging leading to intervention if possible (e.g., surgery, injections), mild analgesics, and then strong analgesics. The new pathway would begin with measurement (e.g., depression, anxiety, childhood trauma) and continue through a holistic approach to counseling, encouraging of self-help and activation, and ending with mild analgesics.
The CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016 discourages the use of long-acting opioids, suggests dose limitations, recognizes “legacy patients” as a different category, and considers acute opioid use as a pathway to chronic use.18 Dr. Ballantyne listed older theories and matched them with replacement ones (in italics), based on new evidence:
In 2015, Dr. Ballantyne and colleague Mark D. Sullivan, MD, wrote: “We propose that pain intensity is not the best measure of the success of chronic-pain treatment. When pain is chronic, its intensity isn’t a simple measure of something that can be easily fixed. Multiple measures of the complex causes and consequences of pain are needed to elucidate a person’s pain and inform multimodal treatment.”16
Strong reactions to Drs. Ballantyne and Sullivan’s statements were voiced quickly after that publication, with one expert characterizing their recommendations as “totally inappropriate” and calling for Dr. Ballantyne to resign her academic post. Ignoring the authors’ call for “multimodal treatment,” that article states: “Ballantyne and Sullivan offered no alternative ‘fixes’ for pain treatment, other than patients learning to live with pain and sitting down for a chat with their doctors.”24
- Beecher HK. Increased stress and effectiveness of placebos and “active” drugs. Science 1960;132(3419):91–92.
- Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med 1980;302(2):123.
- Portenoy RK, Foley KM. Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain 1986;25(2):171–186.
- Sullivan MD, Ballantyne JC. What are we treating with long-term opioid therapy? Arch Intern Med 2012;172(5):433–434.
- Ballantyne JC, Sullivan MD. Intensity of chronic pain—the wrong metric? N Engl J Med 2015;373(22):2098–2099.
- Franklin GM; American Academy of Neurology. Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology 2014;83(14):1277–1284.
- Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep 2016;65(RR-1):1–49.
- Sullivan MD, Edlund MJ, Zhang L, et al. Association between mental health disorders, problem drug use, and regular prescription opioid use. Arch Intern Med 2006;166(19):2087–2093.
- Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain 2015;156(4):569–576.
- Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2015;162(4):276–286.
- Le Marec T, Marie-Claire C, Noble F, Marie N. Chronic and intermittent morphine treatment differently regulates opioid and dopamine systems: a role in locomotor sensitization. Psychopharmacology (Berl) 2011;216(2):297–303.
- Yu G, Zhang FQ, Tang SE, et al. Continuous infusion versus intermittent bolus dosing of morphine: a comparison of analgesia, tolerance, and subsequent voluntary morphine intake. J Psychiatr Res 2014;59:161–166.
- Anson P. Controversy grows over journal article on pain treatment. Pain News Network. December 10, 2015. Available at: www.painnewsnetwork.org/stories/2015/12/10/controversy-grows-over-journal-article-on-pain-treatment. Accessed March 1, 1017.