Future of Opioids, Pain Management? Lets Hope Not

Letters

BY DR. RICHARD A LAWHERN SRQ DAILY SATURDAY PERSPECTIVES EDITION SATURDAY MAR 31, 2018

On March 24, 2018, SRQ ran an article by Dr. Fabian A Ramos, on the future of opioids and pain management. From 20 years of analyzing medical literature as a technically trained non-physician patient advocate, I suggest that Dr. Ramos got several facts wrong.

Dr. Ramos writes: "According to a recent study, opioids claimed the lives of approximately 16 Florida residents per day in 2016, mostly from legally prescribed sources.”

My response:  Data from the National Center on Health Statistics indicate that, in 2016, there were 15,400 deaths in the US from prescription opioids and 35,500 from heroin and fentanyl.

D.r Ramos claims: "Lowering effective milligram dosages proactively manages the risk of instances of addiction and overdose."

My response: There is no published medical evidence for this speculation. To the contrary, data from a 2016 Commonwealth of Massachusetts study[i] actually suggest that stopping prescription opioids may have contributed to significant numbers of overdose deaths.

We also know opioid analgesics provided to millions of post-surgical patients entail a risk of later opioid abuse or extended prescription of less than 1 percent. This outcome directly contradicts the notion doctors prescribing for pain patients have fed an “opioid epidemic”. Lowering doses ensures patients will be subjected to agony when reduced below minimum therapeutic levels. Some of these patients commit suicide. Others accidentally overdose when forced to seek pain relief in unregulated street markets.

Dr. Ramos continues: "Nearly 25 percent of referred patients are not accepted into our practice, largely due to excessive opioid prescriptions. Before we can treat these cases, we require rehabilitation or detox… Of our 10,000-plus active patients, only 18 percent are prescribed opioids for pain management, 97 percent are insured—contrasting opioid-only clinics with a cash-based model—and only 1 percent are under 30 years old."

My response: Dr. Ramos’ statistics on opioid restriction and his stigmatization of patients seem to me to represent medical failure, not success. His reference to “opioid only clinics” is a thinly veiled jab at so-called pill mills, which nobody would claim as appropriate models for pain management. 

The precision of medical literature on non-pharmacological, non-invasive therapies (including mental health counseling) is abysmal. A recently circulated draft review of over 4,500 published trials demonstrates that such therapies are not reliably successful as replacements for opioid therapy. Their appropriate role is as adjuncts to "usual therapy" with anti-inflammatory medication or opioid analgesics.

A viable future for pain management requires that we find balance in our public narratives concerning addiction and chronic pain. Opioid analgesics must continue to play a central role and doctors must be much better trained to tailor treatment to individual patient needs.

Dr. Richard A Lawhern is the co-Founder and corresponding Secretary for the Alliance for the Treatment of Intractable Pain.

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