Americans consume 80 percent of the opioid painkillers prescribed worldwide, ultimately resulting in the deaths of more than 20,000 Americans each year of overdoses of these drugs. The crisis is making doctors look at alternative medicine therapies for a substitute for these drugs. Experts discuss modalities that have shown success.
- Dr. Josie Briggs, Director, National Center for Complementary and Integrative Health, National Institutes of Health
- Dr. Roger Chou, Professor of Medicine, Oregon Health and Science University and Director, Pacific Northwest Evidence Based Practice Center
- Dr. David Miller, acupuncturist and medical doctor, East West Integrated Medicine, Chicago, and spokesperson, National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM)
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Reed Pence: People usually start taking opioid painkillers innocently. They want pain relief, and they want it quickly. Their doctors comply and a relatively small proportion will eventually become addicted. Some of those will end up in mortal danger as a result. In 2015, more than 20,000 people in the U.S. died of an overdose of prescription painkillers. And finally Americans have been jarred awake to the crisis. Today, the United States consumes 80 percent of the world’s prescription opioid drug supply, more than 200 million prescriptions per year. But why this imbalance? Are Americans just in more pain than the rest of the world?
Briggs: The numbers you cite are indeed worrisome. What’s especially worrisome is the terrible death rate we are seeing right now from opioids.
Pence: That’s Dr. Josie Briggs, director of the National Center for Complementary and Integrative Health at the National Institutes of Health.
Briggs: Pain management for every country I think is not without its problems, and that we have a healthcare system that isn’t doing a great job is something I am very acutely aware of. I haven’t however, seen good international comparisons to tell us that this problem has been solved anywhere. We do see the problems related to over reliance on opioids as a real major healthcare crisis right now.
Chou: In the United States we do quite a few things differently than the rest of the world for medical care in general. As you know we spend more per capita on medical care than any country in the world to begin with. And then when you look at specific things like management of pain we differ not just with opioids but with a lot of other things. We do a lot more surgery than any other country; we do a lot more MRIs than any other country. So opioids, the statistics are striking, but it’s not the only area where we see that the United States differs.
Pence: That’s Dr. Roger Chou, professor in the department of medicine at Oregon Health and Science University and Director of the Pacific Northwest Evidence Based Practice Center. Chou says back in the 1980s, doctors didn’t use opioids to manage chronic pain; they were only indicated for temporary acute pain, such as that caused by surgery or bone fracture.
Chou: Starting in the 90s that really shifted. There was a lot of belief that we weren’t adequately treating chronic pain. We have a lot of people with chronic pain in this country. And there was a feeling why aren’t we using opioids, which are what we think of as the most powerful painkiller. And there were some though very limited data that opioids might be safe and effective for this use. There were actually regulations passed in many states to make striating chronic pain with opioids allowable so doctors wouldn’t be afraid of getting into trouble for doing this.
Pence: Another change in medical practice at about that time was that pain became known as the fifth vital sign.
Chou: You were required to measure pain in every patient every time they are seen in the clinic or the hospital. People were getting scored on this, so people were afraid, they felt they needed to treat it and again, opioids were there and they were told that they were safe and effective. There were several drugs that came onto the market around that time for example OxyContin or sustained release oxycodone, which was in many places it was the most costly drug to the formulary for a period of time.
Pence: Costly…and for the companies that made them, highly profitable.
Chou: Industry does have a role in this. When OxyContin was released that was accompanied by really an unprecedented marketing push and some misleading information. They said that you didn’t develop tolerance and you wouldn’t withdraw if you were given that medication; so that was part of it. I think that people don’t remember or recognize that two executives from Purdue Pharma pleaded guilty to telling misleading information to the FDA and they served some jail time and Purdue Pharma was fined $500 million.
Pence: For doctors though, Chou says it was simply a desire to treat their patients.
Chou: I think it was this well-meaning intention to help patients who were with chronic pain, not understanding all the data or the risks and benefits of the therapy. And then you get kind of the pharmaceutical company side. So a lot of things that all came together.
Pence: But if opioids aren’t the answer for treating pain, then what? Doctors can’t leave patients with nothing. Finally the medical world is looking at non–pharmacological therapies for chronic pain — what a lot of people call alternative medicine, modalities such as s spinal manipulation or chiropractic care, massage therapy, acupuncture, traditional Chinese medicine, yoga, tai chi, cognitive behavioral therapy and even meditation and mindfulness training.
Briggs: One of the places we’re partnering with is the veterans administration. The VA has widespread recognition that pain management for veterans is a tough problem and VAs are frequently incorporating acupuncture, yoga, chiropractic care, massage therapy into the care that they offer patients. The center that I lead is in the research business. We support researchers who try to figure out what works and the evidence is still incomplete, but part of what is contributing to this change are the kinds of research studies that are shown that things like yoga seem to help people with chronic low back pain. So it’s an exciting time for change in the way the research that we’ve been supporting is affecting healthcare.
Miller: A lot of pain that comes from orthopedic injury and orthopedic surgery comes from muscle dysfunction. It happens because you’ve disrupted movement around a joint or the muscular sort of balance of the body. And muscular pain can be really quite profound. A lot of migraine pain, a lot of severe headache or orthopedic pain that you see in the clinical environment is really caused by muscular dysfunction.
Pence: That’s Dr. David Miller, licensed acupuncturist and medical doctor with East West Integrated Medicine In Chicago. He’s also a spokesperson for the National Certification Commission for Acupuncture and Oriental Medicine or NCCAOM.
Miller: And acupuncture is an ideal tool for relieving muscular dysfunction and helping cue the body to go back to understanding how do I use myself correctly, biomechanically after having had this insult to the body, which may have been a necessary insult, but nevertheless requires this healing and reorganization. So acupuncture does a couple of things to sum it up. One it cause you to release your own natural pain killing chemicals, two it can modulate the way you perceive pain, and three it can help relax muscles and help the body restore normalcy of function in its biomechanics of movement.
Pence: The American College of Physicians recently released new clinical practice guidelines on managing low back pain incorporating some of these alternative modalities into patient care. But releasing new guidelines doesn’t automatically mean that doctors will follow them or that patients will accept them.
Chou: When I talk to physicians I tell them it’s important to talk to your patients, understand what therapies they’re interested in. It’s probably not going to be that helpful to send somebody to acupuncture who doesn’t think acupuncture makes any sense. We’re mostly trained in a traditional medical paradigm and it tends to be a much more drug-based treatment approach is what most people are familiar with and comfortable with and frankly it’s a lot easier. It’s typically a lot easier for someone to just write a prescription for a pain pill than to talk with the patient about what kinds of therapies might be useful for them.
Pence: And even if doctors might be willing to recommend alternative therapies to their patients, many of them don’t know who to refer their patients to.
Chou: For example, if I want to get somebody into a spinal manipulation there’s insurance coverage areas that I have to deal with. I often am not familiar with the chiropractors in the community, so it’s hard for me to know who to refer somebody to. There’s more paperwork; I often have to write a letter or do some other justification for it. Whereas if I want to send somebody to the surgeon it’s a simple click something on the computer essentially.
Pence: Another barrier to alternative therapy treatment is cost. As Chou mentions, and Miller confirms, many insurance companies don’t cover them.
Miller: We also need to be really pushing out insurance companies to cover these services so that they become viable for everybody and not just those who can afford to pay out off pocket.
Briggs: Pain management is a real driver of healthcare costs. Medicare does cover some of these approaches and insurers will make policy decisions driven in part by the evolving importance of the evidence and the status of the evidence.
Chou: These therapies are a lot harder to study than drug therapies. If you think about a drug therapy it’s easy to give somebody a pill, that’s the true drug and a fake pill or placebo that looks like the true drug, but is just a sugar pill. They don’t know which one is which and you can do a good double blind standard trial like that. It’s really much harder to do that with things like exercise and acupuncture and yoga. Trying to give someone pretend yoga or pretend acupuncture, manipulation is quite difficult.
Pence: However, data is improving. Research subjects say they experience about the same level of pain relief and normal function using alternative therapies as they do when using opioids.
Chou: For example with yoga or something like spinal manipulation you get on average about one point pain relief on a one to ten pain scale, which doesn’t sound like a lot, but then when you look at opioids the average pain relief is maybe a point and a half to two points. So it’s really not that different and of course they are much safer.
Pence: Chou stresses that both doctors and patients need to adjust expectations when it comes to relieving chronic pain.
Chou: When people talk about chronic pain a lot of times they assume that patients want to have their pain gone, which is true to some extent, but if you really talk to people what they say is I want to have my life back. That means getting people functional, getting them back to work, getting them to the point where they can enjoy life and engage with their friends and family. They may involve having some degree of pain, but being able to manage and deal with it. That’s where we want to get them. It’s actually very hard for us to eliminate pain. For many people that’s not a realistic goal.
Pence: Experts are not saying we need to get rid of opioid pain killers altogether. Even alternative therapy practitioners like Miller say opioids have their place.
Miller: There is an appropriate use of opioids in some situations and in situations where patients have extreme pain for some reason, that’s an appropriate place to use opioids on a very controlled temporary basis, in a very monitored basis.
Chou: It’s just that we need to be much more cautious and selective about how we use them. We were pretty cavalier about how we used those medications and we know all the statistics now, the thousands of overdose deaths that occur every year related to prescription opioids and the fact that most patients aren’t all that much better-off on the pain medications than they would be without them. There are some people that we can use relatively low doses as long as we are monitoring them appropriately, but it should not be the mainstay of therapy. Giving somebody a pain pill doesn’t address any of these psychosocial and other contributors to chronic pain that we know are so important now.
Pence: In other words, they don’t address the problem behind the pain, they just cover it up. But it’ll take a long time to incorporate alternative therapies into mainstream medical practice. Both doctors and patients will need time to get used to the idea, and education about how these alternative therapies work. Physicians and insurance companies will also require evidence of their effectiveness. But for many current clients of these therapies, the pain relief they experience is all the proof they need. You can learn more about all of our guests and alternative therapies for pain management by visiting our web site at radio health journal dot net. Our writer/producer this week is Polly Hansen. I’m Reed Pence.