Steven Passik: To Use Opioids Safely, We Need to Stop Blaming the Drugs
I contacted Steven Passik, a professor of psychiatry and anesthesiology at Vanderbilt University, about a paper he had co-authored for the November 2010 edition of the American Journal of Bioethics. He invited me to come hear him speak at Pain Week in Las Vegas next month. I wish I could be there. His talk is titled “Jesus, Bacon, and Hyperalgesia: Intellectual Honesty and Dishonesty in Opioids for Chronic Pain Management.”
One can only imagine the type of post-panel discussion that one will generate. Passik writes about pain management after having worked in academia and with industry. He has received research grant support from Cephalon and Ligand Pharmaceuticals and has been paid as a consultant for Cephalon, Ligand Pharmaceuticals, Eli Lilly and Company, Janssen, and King Pharmaceuticals, Inc. I asked him to share some of his thoughts with all of you.
Here is his guest post:
As a person who was trained in both pain and addiction, I have felt the need to throw my weight from one side to the other as the pendulum on opioids swings back and forth. There are millions of people in the US suffering from chronic pain. The idea that any one therapy – opioids, physical therapy, surgery – is right or wrong for all or even most of those people is absurd and an argument not even worth having.
When the opiophiles were trivializing addiction in the early days, I was seen as a bit of a party pooper talking about the risks and cutting back on the rhetoric. I wrote a letter to the editor to Journal of Pain and Symptom Management in 2001 warning about prescription drug abuse, which is one of the most referenced things I have ever written. I should note that I don’t think of everything the opiophiles were pushing for was quite as diabolical as has been being made out in retrospect. It was a naive and almost religiously well-intentioned movement in those days. People really thought that if we "liberalized opioids" pain would be eradicated.
Compare that to today. I have patients on stable doses of opioids, with no histories of misuse or abuse, some with histories of cancer, being turned away by prescribers running scared of new laws and/or harboring views of opioids in which they believe that addiction, tolerance, hyperalgesia, which is an increased sensitivity to pain, and other negative effects of opioids are inevitable. And they blame the drugs themselves for the problem as if addiction lives in drugs; or as William Burroughs put it, “Addiction is a disease of exposure.”
This is the first mistake of the opiophobes. Blame the opioids themselves. In fact, we have never had a health care system that allows for their safe, individualized (tailored to the person) use.
If I speak to a group of doctors over dinner, nearly all of them will have a cocktail or a glass of wine in front of them. And as a teaching exercise, I might ask them whether alcohol is an addictive drug? They all raise their hands to say they think it is. And so I ask them “why are you drinking then? Aren’t you afraid you could lose it all?” The docs know that alcohol exposure in the US is nearly universal, with the exception of certain religious groups. Yet the rate of alcoholism is 8% of American adults.
Alcoholism is the end result of exposure to alcohol in people with psychiatric, genetic, spiritual and familial vulnerabilities at vulnerable times in their lives (i.e., during times of stress). The same is true of all drugs, including opioids. Addiction is the result of exposure to a substance in a vulnerable person at a vulnerable time.
In pain management, no exposure of anyone at all means cutting off an avenue to relief for a subset of people with pain that might otherwise do well. Safe opioid prescribing is the result of assessing the (known set of) vulnerabilities in these highly stressed people (as all people with chronic pain are) and accommodating the delivery of opioid therapy to them. Rather than blame the drugs, we should ask why we have not been able to incorporate this simple axiom into pain management.
I shared an early version of a talk I will be giving during the upcoming Pain Week, in which I made the above argument, and a colleague said to me, "I didn’t realize you were so pro-opioid."
My response: "I'm not pro opioid. I am anti-BS."
We are now living in a moment when, as my colleague’s comment showed me, even people who have been critical of overuse of opioids or balanced about them can be considered pro-painkiller. And we are coming out of a period when arguing for a balanced approach made you seem like a party pooper. I have patients who have been seeing the same doctors for years only to have these doctors refusing to write them a prescription. We’re not talking about unbalanced individuals with criminal histories. We’re talking about stable, low-risk people.
While advising a pharmaceutical company, I saw a statistic recently based on IMS Health data that 8.8 million people are on chronic opioid therapy and 5.5 million of them are on hydrocodone. Now, putting aside the fact that hydrocodone and other short acting opioids are not considered right for every person along the spectrum of pain and risk for addiction, could we possibly be doing things right if more than 60 some odd percent of patients are on the same drug?
Hydrocodone therapy, in patients seen once a month with no other multidimensional treatment, is good only for a very small sliver of the pain population. This is what I call minimally monitored, drug-only pain therapy. But still this is the prevailing model, and thus a very easy straw man of opioid therapy that can be knocked down with a stiff breeze. It is not a model of opioid therapy suitable for higher risk patients.
So why is this the prevailing model?
Howard Heit, Doug Gourlay, and many others have said the same thing for years. The third party payers have been a big impediment to doing it right for the patients who need more. To treat a patient as an individual with specific needs, a doctor needs to consider a range of treatment options, including psychological care, rehabilitation, physical therapy, monitoring with urine drug screens and the drugs themselves. This is a more comprehensive strategy and more likely to be met with success in higher risk patients. But it also requires more time and resources than a doctor spending a few minutes with a patient and prescribing a pill.
That’s why payers prefer pills. Yet the payers never seem to get their share of the blame for the prescription abuse epidemic that is, in part, a byproduct of the pressure of trying to do opioid management on the cheap.
Photo credit: Robson# via Flickr