What to Do When Painkillers Don’t Work
June 6, 2012
Doctors prescribe more painkillers today than they ever have — writing three times as many prescriptions for opioids as they did 20 years ago, according to the Centers for Disease Control and Prevention (CDC).
Chronic pain is a significant problem affecting more than 100 million Americans, according to the National Institutes of Health (NIH). This puts doctors who treat pain in a tough spot. Opioids come with major side effects, including mental clouding, nausea, and the potential for respiratory depression, which can cause death. There is also a risk of developing a physical dependence on them.
To examine this issue, a group of panelists met in September 2014 at an NIH Pathways to Prevention workshop. They found that most studies on opioid painkillers for chronic pain were too short — some less than six weeks — and that there was evidence of increased risk for overdose and abuse.
“At the conclusion of the workshop, we called for further study of opioids in the treatment of chronic pain,” says David C. Steffens, MD, MHS, a professor and chair of psychiatry at the University of Connecticut Health Center School of Medicine who took part in the two-day workshop. “We hope those who prescribe these medications for acute pain, such as in the context of a work or sports injury, will be cautious about the number of pills they prescribe.”
Dr. Steffens and his fellow panelists also came to the conclusion that a large part of the problem is lack of knowledge on the best ways to treat pain, and a health care system that often defaults to the easiest, rather than the best solution.
Looking at the Person Behind the Pain
What do these findings mean for physicians who regularly prescribe opioid painkillers for chronic pain?
“They mean we are going to have to be much more thoughtful and creative about how we manage chronic pain,” says Gary Kaplan, DO, founder and medical director of the Kaplan Center for Integrative Medicine, and author of Total Recovery: Solving the Mystery of Chronic Pain and Depression. “We too often treat the thing and not the person.”
Dr. Kaplan also says the report shows the best use for opioid painkillers is for short-term pain, like post-surgical pain, and not chronic pain conditions.
Supporters of the findings also say the health care community needs to be more careful about which patients get prescriptions for narcotics.
“For people with addictive personalities, opioid painkillers can be very tempting,” says John Stamatos, MD, director of pain management services at Syosset Hospital in Syosset, New York. “The problem is the body gets tolerant to these medications, and patients require more and more over time. Unless we monitor patients closely, this can quickly get out of control.”
But he points out that there are some patients who absolutely need opioid painkillers.
“If you have a patient who has had three back surgeries and is still miserable, what are you going to do with that patient — say, ‘Just deal with it’?” says Dr. Stamatos. “We can’t just leave these people to wait out their life with severe pain.”
To monitor his own patients, Stamatos observes how they function each day. “I look at whether patients are making it to work, exercising, taking care of their kids, and doing all the other things they need to do in their daily lives,” he says. “If they are just lying on the couch, they are clearly not using painkillers appropriately.”
A Different Approach to Pain Management
There are alternatives to opioids, including injections, muscle relaxants, or non-narcotic painkillers like non-steroidal anti-inflammatory medications (NSAIDs), Stamatos says.
“Science is also showing us that techniques such as acupuncture, meditation, and nutrition play a very important role in the management of chronic pain and are far too underutilized,” Kaplan says.
Exercise can also work wonders. “Physical activity helps strengthen the muscles around whatever is injured so you can get back to your life,” Stamatos says.
One takeaway from the NIH workshop on opioid painkillers is that doctors need to be careful, Kaplan says. “Physicians have been too quick to prescribe opioid painkillers,” he says. “We need a more thoughtful and comprehensive approach to the treatment of chronic pain.”