The Challenge of Pain and Opioid Use

In the three decades I have practiced as a psychiatrist the most difficult and challenging individuals I encountered suffered with intractable chronic pain, opioid substance use disorders and people who lost a child, sibling, parent or friend to opioid overdose and individuals who suffered as a consequence of their encounter with the criminal justice

system. This is not surprising, chronic pain afflicts one in three Americans. More and more individuals suffer with Opioid Use Disorders, including legally prescribed opioids as well as illicitly acquired prescription opioids and heroin. The War on Drugs has been the dominant policy response, devastating individual lives and communities with limited success in achieving its stated purpose of ridding society of drugs. It is clear that a different approach is needed. Fundamental to a meaningful, successful plan to address the challenge is having a clear understanding of the “symptoms” / challenges. Treating individual in the medical setting I relied on developing a problem list that reflected the individual’s symptoms. I realize that unless we address the factors that lead to the problems individual experience, little change will take place. To start with we need to have a problem list of the societal interconnected challenges of the Pain Opioid Epidemic. Here is a problem list derived from the symptoms driving the Epidemic:

1. Pain and its management: Pain is an ever present human condition. The medical profession has a moral imperative to alleviate the suffering associated with pain. For various reasons over, under and inappropriate prescribing of opioids for pain conditions is common. Recently, responding to regulatory and criminal justice activity, the medical community has been going through a profound change in the “Culture of Prescribing”. New guidelines for physicians in primary care have further eroded clinician's treatment choice. Financial incentives, insurance guidelines, Laws and policies impact the ability of individuals to get the Non Opioid based pain relief.

2. Prescription opioid overdose: As a result of many factors more and more Americans are dependent on opioids for medical as well as non-medical reasons. For various reasons, prescription opioids have directly contributed to over 18,000 deaths in 2014. What is clear is that prescription Opioids contributing to the fatal overdose originated with a legal prescription. It is not clear what is the percent of people who suffered consequences adhering to medical prescribed opioid treatment. It is clear that unintended use of prescription opioids through diversion, access by family members, etc. is common.

3. Opioid Use Disorders: There is an increasing number of Americans dependent on opioids. Some are able to get their medication through the medical establishment. Others resort to the illegal/ illicit drug market where they have access to prescription opioids as well as Heroin.

There is limited research about the causes of dependence and addiction as well as scientific treatments. Treatment for Opioid Use Disorders has evolved and currently there are a number of promising treatments.

4. Opioid dependence and addiction treatment: Opioid Use Disorders are chronic, relapsing multi factorial brain conditions that responds to bio-psycho-social- spiritual** informed treatment. Individuals suffering with Opioid Use Disorders, confront many obstacles to receive evidence based, best practice treatment. More specifically, many treatment settings are driven by ideologically motivated rather than scientifically derived treatment approach. Individuals are limited in their access to effective treatment due to cost and other challenges.

5. The criminalization of opioid use: The "War on Drug" initiated to rid society of drugs has been increasingly recognized as a failure. Not only has Opioid (and other drugs) have continued to be available to the millions of individuals who choose/ or are addicted to them, but the societal devastation inflicted by the various levels of government has been disastrous for many nations and communities. The consequences of policies and actions associated with the drug wars have been noted to exacerbate the negative consequences.

6. The cost of the "War on drugs": The drug war has diverted important funds to achieve increasingly harmful results. Rather than spending societal resources on social programs that promote individual and community well being, the drug war has left in its wake traumatized individuals and devastated impoverished communities.