In several past articles on the opioid epidemic in America, I have complained that the problem of severe, chronic pain has been overlooked as a contributing factor. It appears that that is no longer true.
For example, a very recent report by the National Academies of Science to the Food and Drug Administration begins, “The ongoing opioid crisis lies at the intersection of two substantial challenges—reducing the burden of suffering from pain and containing the rising toll of the harms that can result from the use of opioid medications.”
In addition, before he resigned, the Secretary of HHS has included “advancing better practices for pain management” on the department’s list of 5 major priorities regarding the opioid epidemic. This includes increased research about how to treat pain effectively as well as increased education of both providers and the general public regarding the safe, limited use of opioids and effective pain management alternatives. Secretary Price had also endorsed the National Pain Strategy, which was issued towards the end of the Obama administration.
There are reasons to believe that the Federal government will increase its efforts to address the opioid epidemic and the problem of pain management. Most importantly, pursuant to the Cures Act, HHS has recently given about $500 million of grants to address the opioid epidemic and will do so again next year.
However, there are also reasons for concern about this seemingly good news. The effort to “repeal and replace” the Affordable Care Act, which has so far been blocked in the Senate, could re-emerge, placing a cap on Medicaid spending that would result in losses of billions of dollars for treatment as well as cutting millions of people off the health coverage they need to be able to afford comprehensive pain management and treatment for substance abuse and for mental illness (which affects a significant portion of those with substance use disorders).
In addition, President Trump’s recent announcement about a renewed national effort to address the opioid epidemic emphasized a “law and order” approach—more arrests, more imprisonments. That does not suggest an understanding of people living with severe, chronic pain, and it does not auger well for a public health strategy that stresses prevention, treatment, and research rather than moral reproach.
Recent reports providing public health approaches to the problems of pain and addiction all have their own specific recommendations, but the cornerstones of the various proposals are remarkably similar and include:
- Professional and public education with an emphasis on limited and careful use of opioids when necessary and on the use of pharmaceutical and non-pharmaceutical alternatives so as to avoid risks of opioid use, which range from constipation (far more serious than generally acknowledged) to cognitive impairment to addiction to overdose
- Increased use of interventions to prevent, treat, and reduce the potential harmful consequences of addiction including making drugs that reverse overdoses readily available to first responders
- Oversight of physicians and pharmacies to identify those with questionable practices and then to provide education, remove licenses, or pursue criminal prosecution as appropriate
- Conducting more epidemiological, clinical, and biomedical research to identify effective ways to manage pain, to prevent and treat addiction, and to disrupt the pathway that 5-10% of those prescribed opioids follow from pain management to addiction to lethal street drugs. Understanding this pathway is particularly important because upwards of 75% of current heroin users began with a prescription painkiller, which may or may not have been prescribed for them.
Secretary Price, to his credit, has also noted the importance of understanding the social and psychological factors that contribute to rising substance abuse and suicide. “We must not forget”, he said recently, “the types of pain that can hurt the most but are often the hardest to treat—the pain of loneliness and despair, of feeling unloved or unvalued…. Today’s epidemic…is the story of…our search for meaning and purpose in a broken world.”
Of course, what he has in mind as a “broken world” is far more about the decline of religious faith than the growth of disparity and the rising economic and racial divide in America. Still it is encouraging that the Secretary of Health and Human Services in the current administration sees the problem of pain, rather than moral decay, as a critical root of the opioid epidemic.
But talk is cheap; action costs money. The current federal administration still seems intent on undercutting health policies that make treatment affordable and on vastly reducing spending on social programs. Without funding for prevention and treatment, for education and research, and for efforts to build stronger communities, there is every reason to believe that very good recent federal reports and strategies will join many others gathering dust on the long-forgotten shelves of history.
Michael B. Friedman, MSW is Chair of the Geriatric Mental Health Alliance of New York.
- Bonnie, RJ et al (2017). Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. National Academies of Sciences, Engineering, and Medicine. Forthcoming. http://www.nationalacademies.org/hmd/Reports/2017/pain-management-and-the-opioid-epidemic.aspx
- National Institute on Drug Abuse (2017). “Opioid Crisis”. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis
- National Institutes on Health (2016). The National Pain Strategy. https://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm
- President’s Commission on Combating Drug Addiction and the Opioid Crisis (2017). Draft Interim Report. https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf
- Price, TE (2017). “Secretary Price Announces HHS Strategy for Fighting Opioid Crisis”. https://www.hhs.gov/about/leadership/secretary/speeches/2017-speeches/secretary-price-announces-hhs-strategy-for-fighting-opioid-crisis/index.html
- U.S. Department of Health and Human Services (HHS) Office of the Surgeon General (2016). Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. https://addiction.surgeongeneral.gov/