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Busting Pain Medicine Myths with Andrew Kolodny

Busting Pain Medicine Myths with Andrew Kolodny

Dr. Andrew Kolodny is the Chief Medical Officer and Senior Vice President at Phoenix House Foundation in New York. He’s also a go-to source for journalists looking for perspective on the nation’s prescription drug abuse problem. He first contacted me a year ago when I interviewed writer Maia Szalavitz about her thoughts on painkiller addiction. She thinks that anti-drug hysteria is more harmful to addicts than cracking down on physicians who overprescribe painkillers. Kolodny questioned some of the statistics she used to back up her arguments. Now he has a position where he can, potentially, put a lot of his ideas into action on a large scale. Phoenix House is one of the largest nonprofit chains of drug treatment centers in the country. I reached him via email. The first part of our interview is below. More will come in later posts.

Q: You trained in psychiatry and are a board certified psychiatrist. What drew you to pain management?

A: After finishing my psychiatric training, I began working for New York City’s health department. My first assignment was to reduce drug overdose deaths. This was in the early 2000s, when trends indicating a new epidemic of opioid addiction and overdose deaths were just beginning to emerge. I’ve remained concerned about this public health crisis since then.

See Also: Andrew Kolodny Interview Part 2: Taking a Public Health Approach to Pain Treatment

I became especially interested in opioid use for chronic non-cancer pain after reading a 2006 study by Leonard Paulozzi from the Centers for Disease Control and Prevention (CDC). In the article, Dr. Paulozzi demonstrated that opioid overdose deaths were increasing in parallel with increases in opioid prescribing. He argued that aggressive pain management with opioids was leading to skyrocketing rates of overdose deaths. Since then, the CDC has continued to release data indicating that sharp increases in opioid prescribing have been associated with similar increases in opioid addiction and overdose deaths.

Q: There has been much written in the scientific literature and in the media about pain and pain management over the last decade. Yet we still appear to lack an effective toolkit for treating the range of pain problems that affect people. Why do you think that is?

A: I don’t believe we’re lacking “an effective toolkit” for treating pain. There are many treatments for pain that are effective. The problem is that many of these treatments involve more effort and expense than simply giving out pills. As a society, we’ve grown accustomed to believe there’s a pill for every ill. This mindset has been encouraged by the pharmaceutical industry. In the short run, this also works out well for health insurance companies because a quick primary care visit and a prescription may cost less than more effective treatments and interdisciplinary care.

Q: One of the numbers often cited in the media and the literature about the extent of the pain problem in the United States is that 75 million to 150 million people are in chronic pain. By my count, that would mean that as many as 1 out of every 2 people are in chronic pain in the United States. Does that seem reasonable?

A: Feeling pain is part of being alive, so I have no doubt that millions of Americans frequently experience pain. And with baby boomers aging and with obesity rates increasing, it’s likely that the number of Americans suffering with chronic pain is increasing, too.  But these estimates don’t make sense to me. The suggestion that half of our population is disabled from “the disease of chronic pain” is silly. The pain industry and its key opinion leaders have promoted these figures.

Q: You wrote in the New York Times that doctors should pull back from prescribing opioids for chronic pain. What effective options are left then for treating chronic pain?

A: For chronic pain sufferers, the most important thing their doctors can do is find the underlying cause of the pain and, where possible, treat the problem that’s causing the pain. Too often, this doesn’t happen and instead the patient is simply prescribed a narcotic.  Effective interventions for chronic pain may include physical therapy, non-opioid analgesics, weight loss, exercise, cognitive-behavioral therapy (CBT) and many other treatments.

Opioids are an important class of medication for easing suffering at the end of life and when prescribed short–term for severe acute pain. But when opioids are prescribed long-term for chronic pain, we may actually be harming far more patients than we’re helping. The problem goes well beyond the risk of addiction and other serious side effects. It’s that they don’t seem to work well when taken long-term and may actually make pain worse, a phenomenon known as hyperalgesia. At Cleveland Clinic, Mayo Clinic and other prominent medical centers, the treatment for chronic pain often begins with slowly tapering patients off of their opioids. Many patients actually have better pain control and improved function after they come off opioids. The fact that opioids don’t work well for most people with chronic pain has been discussed recently in numerous medical journals. It’s also the subject of a new book by New York Times reporter Barry Meier called “A World of Hurt: Fixing Pain Medicine’s Biggest Mistake.”

Q: The thing about pain pills is that they are a simple and relatively low cost therapy. More complicated therapies tend to cost more and require more patient engagement, which can led to less patient compliance. For a large number of people, is it realistic to think the health care system can cost-effectively deal with chronic pain by using non-pharmaceutical approaches?

A: It’s true that caring for someone with chronic pain in an interdisciplinary pain care program will cost more than giving out pills – more upfront that is. But not in the long run. Prescribing opioids for chronic pain is pennywise and pound foolish. As an example, just consider what’s happening in the workers’ comp arena. Injured workers who have their chronic pain treated with opioids are less likely to go back to work again compared to other interventions they could have received.  And since many workers wind up stuck on opioids, the medication costs begin to add up. For medication costs alone, workplace insurers are now spending about $1.4 billion per year on opioids.  Additionally, overprescribing of opioids is associated with sharp increases in the prevalence of opioid addiction, a chronic disease that is expensive to treat and strains the economy in many other ways. Some of these costs were nicely outlined in a recent New York Times article called “The Soaring Cost of the Opioid Economy.”

We’re just talking about the economic costs but we also have to consider human costs. By prescribing opioids to chronic pain patients, a treatment that’s unlikely to work and may even worsen pain, the medical community is undertreating pain and failing in its responsibility to ease suffering. And if the pain patient becomes opioid addicted, they’ll be left with a devastating chronic disease that may kill them. Of course, there’s also the collateral suffering experienced by friends and family members, especially when an opioid addicted individual dies from an overdose.

Image by Colin Logan via Flickr

Comments

I am a chronic pain patient who is prescribed opioids. First of all, the doctor states that patients such as myself will become addicted. I have questioned my doctors about this & have signed documents of agreement & understanding & the physical state of a person taking opioids is described as "dependency". I have also questioned the difference between these words & while I'm not researching the answer for this comment & I can't quote my doctors, dependency means the reaction of the body to the medication - & our bodies become dependent on many necessary medications, not just controlled medications, while addiction results from the unnecessary use of opioids with effects not experienced when the body has a need for & uses it as intended - for the treatment of pain.

I also went to rehab for my chronic pain & the opioids do not work properly when any of the parts of my pain therapy are not followed. These include proper eating, sleeping, toileting, hydration, exercising, medication administration & more. Because my prescriptions are highly controlled, there is no messing about with the doses. Too little & I can't function, too much & it won't last until my next (monthly) appointment. Additionally, these medications aren't made in unlimited dosages. There is an upper end beyond which one would be prescribed another medication with more side effects or reach their level of tolerance without any acceptable treatment for their pain.

I was not inclined to question the doctors' perspective or sources, but when the article closed with the blatant misuse & overuse of the word "addiction", I found all of his information useless. What a shameless scam putting the welfare of patients like myself at severe risk. I'm not sure I could bear to live with my pain untreated &, yes, my opioid medication is an essential part of that treatment (as are the analgesics I am also prescribed).

I would have expected more from public media, but as I think about it, I ask myself, why? It's easy to pull a scam on those with a knee-jerk reaction to certain 'easy to scorn' topics like Drug Use. Most Baby Boomers know someone with a chronic pain issue who may be treated with opioids, but they may not reveal this to all & sundry for a variety of prudent reasons, not the least of which is the scorn & disrespect with which we are often met.

I have had disabling chronic pain from EDS since 1995, but taking opiate pain medication allows me to have a life more than laying on the couch. I tried doing without opiates, but my life was so miserable I wanted to kill myself. Luckily, the addiction counselor I was sent to suggested I go back on them before I did that. Now I'm able to walk a little, drive a little, and visit a little instead of being confined to the couch or bed.

I don't understand why you want to take away the only therapy that has relieved some of my intractable pain. Over 12 years (until I was diagnosed with Ehlers-Danlos Syndrome) I spent thousands of dollars on every possible medical and alternative treatment, but the physical cause of my pain is not curable - I will have to live with it the rest of my life.

Never do I hear you talk about the damage uncontrolled pain does to the human body. There are many scientific studies that demonstrate systemic harm from chronic pain and, as you well know, there are no other effective solutions once pain becomes chronic. There are zero studies that prove opiates don't work long term, so I don't understand how you, a person who has never had chronic pain, can so boldly state this as fact. It is not. Opiates are working for me and many others with lifelong pain - how can you say they do not?

I have never had a problem with opiate pain medications, so I don't understand why you don't want me to take them and condemn me to a life of chronic severe pain. It will be a short one, because suicide would be the only option for me at that point, as it was the last time I tried dealing with my pain without these powerful, literally life-saving, pain medications.

I was given an Epidural Steroid Injection in my Lumbar Spine in 2005, in which the Dr. missed the Epidural Space and injected Depo Medrol into my Spinal Cord. This is a horrible, painful disease without treatment or a cure. How can you even think about making me live in this pain that a Dr. gave me? What happened to do not Harm? If my only treatment for this pain is taken away, mine will be a short one also. Someone who does not know what it is like to suffer with so much pain, does not need to be making decisions on my treatment. I sure hope Karma smiles down on those that want us to continue living, and suffering with this Pain!

I like you am a professional in the field of rehabilitation. I deal with persons who have acquired very real injuries during the course of medical treatment. My specialty is catastrophic injury to the spinal cord and CNS that results in cascading injuries. Do not confuse this type of injury or the needs of these patients with those who abuse these medications for other reasons. To be sure, opioids are not one size fits all solutions. They do not work for some and have little effect for many. But the basis for these injuries is not responsive to other methods of treatment at this time. Epidural injections and dural medical equipment installations are downright dangerous for these consumers, multiplying the effects of their injuries ten told. Until we have real research and integrated treatment teams, your approach is decidedly short sighted and cruel because of your over generalizations. What you should be advocating for is the standardization of the CYP450 to tell us WHO is a candidate for these medications and who is not. You should be advocating for stopping the overuse and misuse of the urine screening protocol as an indicator of abuse for this population. You should be advocating for stopping the use of neuroleptics that are far more dangerous because their effects and injuries are cumulative over time and often not reversible. And finally, you should be working hard to make sure that the iatrogenic events that lead to catastrophic injuries are disclosed, physicians removed from the system and that the reimbursement of dangerous practices that produce huge profits are stopped. When those things have occurred, then we all, including you, have something to talk about.

As this country continues to go deeper into the rabbit hole, every american needs to understand that the figures that Dr Kolodny and others use to promote their agenda are false and manipulated to suit their needs. While it is true that there is a problem with opioid abuse in this country,,, and overdose deaths are on the rise, Blaming this on the patients is cruel at best.... I am aware of many many cases where the death is the direct result of the doctor prescribing the wrong medication to the wrong patient, or the Doctor starts the patient off on way to strong of a dose, or the doctor makes a serious mistake and fails to account for lack of tolerance when switching to stronger medications....Sadly the hundreds of thousands of these iatrogenically caused overdose deaths are blamed on the patient, as no doctor wants to admit he made a mistake and is liable for that persons loss of life.... These figures would paint a much different picture if the real numbers of overdose deaths linked to Bad doctors or stupid mistakes were separated from junkies wanting a fix...It has become common place for the medical community to tweak numbers or skew research data to fit their needs , or hide problems that will implicate them... Adhesive Arachnoiditis is a great example of this dilemma...Today it is fully iatrogenic, and doctors get to hide behind the claims that it is a rare disease therefore are able to continue to practice medicine in a manner that is truly unsafe to the patient. When these doctors make the big mistake that creates another victim of Arachnoiditis they simply deny that the patient has the disease and is able to diagnose them with the biggest lie ever told....Failed back syndrome, or in the case of failed surgery Failed back surgery syndrome.All the time avoiding liability and further skewing the true numbers to suite their needs....The problem with overdose and addiction would be better served if these irresponsible doctors are out of the system...If Dr Kolodny wishes to truly solve this problem, then he should be interested in securing into law regulations that require doctors to report all the errors they make, if these doctors are to be finally help accountable, the numbers of deaths will drop by a number enough to shed a accurate picture on the problem of addiction, not the one they have fabricated to suit their extreme agenda...In short, stop blaming the patient, Hold yourselves accountable.Then lets look at the numbers and find a solution to this problem... until then, leave legitimate chronic pain patients alone and stop trying to convince the media that they are all JUNKIES!!!

Many Americans with back pain are being persuaded to undergo invasive spinal procedures, without fully understanding the risk of permanent injury and harm. Unfortunately, thousands of patients are ending up with arachnoiditis, which is grossly under-reported to the FDA (GAO 2000) and often misdiagnosed (Fibromyalgia, Failed Back Surgery Syndrome or Complex Regional Pain Syndrome). Arachnoiditis is caused by poorly performed spinal procedures - including fusions, unnecessary laminectomies, and epidural steroid injections. Pfizer's Depo-Medrol was recently banned for epidural use in New Zealand (June 2013) because it is a known cause of arachnoiditis, especially if the drug is misplaced during the injection. After patients are harmed, they are often dismissed and abandoned by the medical profession. Opioid therapy is a viable option for many patients suffering from this horrific chronic pain condition for which there is no cure. The PROP Petition overlooked our intractable pain condition and the limited options for pain relief for our growing patient community.

I sound very much like your entire paragraph, but have never heard it explained exactly as you stated.

In the last 24 hours, a critically injured CRPS consumer nearly died from an improperly prescribed dosage of fentanyl delivered transdermally through the use of a patch as a start up dose of 100mcg/hr. This dosage to start may as well have been a bullet delivered to the brain. This has occurred AFTER a pain management specialist talked her out of lesser medications and installed a RECALLED Medtronic pain pump in her buttocks- not only could this not work, but it was not installed properly. At several points in this particular patient's journey she could have died BECAUSE she was a compliant patient. The problem here is not artificial prescribing limits or patient abuse. For the most part it is poor literacy on the part of prescribing physicians, lack of patient education and empowerment, and a system that is stove piped and without monitoring practices, Let's stop the blame and shame game and fix the problem. Artificial limits on prescribing without the application of empirical and scientific practice is just as dangerous as any other game. Today, this patient is alive because of alert patient advocates who are literate, who sent her to the hospital, where her life was saved. Will the doctor who made this prescribing error be reported? Not likely.

As Dr Kolodny rightly states... "There are many treatments for pain that are effective." But there is no silver bullet treatment that works every time and more needs to be done to find effective alternative treatments that are relatively inexpensive with minimal side-effects.

One such treatment was pioneered by a group of neurologists at Vanderbilt Medical University a few years back and the following two case studies of adolescents with debilitating, medication-resistant, chronic pain of the low back and abdomen give hope to many sufferers. These were published in Pediatric Neurology in 2000...
http://www.ncbi.nlm.nih.gov/pubmed/11033291

For the full article, see...
http://www.qmagnets.com/downloads/Qmag_Science.pdf

Its disgusting that some (and unfortunately many who make restrictions on medications) believe this. Im 28, and have been on pain medication since I was 18 due to chronic pain. Ive learned to deal with it, but the stigma the medicine carries and continuing increase of ridiculous restrictions do nothing but make my (and thousands of others’) life harder. People who abuse drugs will abuse drugs, restrictions or not. Saying that painkillers are not effective is absolutely not true. Without them I would be confined to a wheelchair and my home. With them, Im able to go for a short walk maybe once or twice a week. It might not sound like much but it really makes a world of difference. Nevermind the additional suffering I would have to endure 24/7 without them. An earlier commenter mentioned he was close to suicide when going off them, and I was exactly the same way. Unfortunately, those who dont understand chronic pain think people are just being dramatic and saying "give me my pills or I dont want to live". Its not at all. When you struggle through every day just getting from the bed to the couch and back again at night, its not exactly living.

Zyp, love the blog... Keep strong man.

I am so tired of reading articles and interviews that belittle and demoralize patients who live with debilitating pain conditions. First of all, Opioid Induced Hyperalgesia is VERY rare, has mostly been studied in rodents, and is being used as an EXCUSE not to treat patients in pain. It is also being used as a convenient EXCUSE to take patients who are on stable doses of opioids OFF them. This is the biggest scam going in the pain management field right now. Along with the overuse of dangerous injections that have made many physicians millionaires at the expense of trusting, desperate patients. I applaud Dr. Kolodny for his commitment to helping addicts, but I am incredibly disappointed in his lack of education about the benefits of opioids. Unless you have lived with chronic, intractable, severe pain, you don't have a clue about the devastating impact it has on all aspects of life. I suffer from an incurable genetic, connective tissue disorder called Ehlers-danlos syndrome (EDS). I have daily episodes of severe acute pain from chronic joint dislocations and injury, as well as daily chronic pain. Without opioids I would have taken my life years ago. That's not an exaggeration, or a lie. Without the kind of pain relief that opioids have given me, I would have NO pain relief.... and no LIFE. I am physically dependent on opioid medication, which means if I were to stop taking it abruptly, I would suffer from symptoms of withdrawal. THAT is very different from the disease of addiction. Though there is undoubtedly some overlap in these two communities, the vast majority of legitimate pain patients are NOT addicts. We are people who through NO fault of our own, have been dealt a lousy hand with severe health conditions that cause unrelenting pain. To belittle us by saying opioids don't work longterm is insulting, and accusing us of either being dishonest, addicted.....or both. We KNOW whether or not opioids continue to help control our pain.

Please stop perpetuating the lies.... Please stop belittling the seriousness of our pain (or acting as if only cancer pain is deserving of opioids). Please stop telling us about all the wonderful alternatives.... We've either tried them and they failed, or we already use them as adjunct pain therapies. PLEASE stop making our lives even HARDER by suggesting ridiculous, unscientific solutions like daily maximum dosages, or three month limits on our life saving medication. Finally, PLEASE, PLEASE, STOP scaring decent doctors away from treating us! We need all the help we can get, and these lies are ruining what's left of our lives! THANK YOU!

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