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Busting Pain Medicine Myths with Andrew Kolodny
October 25, 2013
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.
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