The Right Policy for Chronic Pain Management

Each year we are treated to alarming rhetoric about deaths among those who abuse prescription pain medications.  We are told that prescription pain medications might be the gateway drug to the use of heroin, a drug unavailable by prescription.  We are offered an easy policy to protect drug abusers from addiction and death – just tighten up the prescribing and dispensing of pain medications, and adopt exercise and aspirin.

Tightening up prescribing and dispensing might protect some abusers, but it will also impede legitimate access to pain killers for the 74 million US adults who suffer from chronic pain.  Drug policy should address the balance between managing chronic non-trivial pain and the prevention of accidental overdose.  Suppression of thrill-seeking drug use should not take precedence over expeditious pain-relief available for legitimate sufferers of non-trivial chronic pain.

In their zeal to limit legitimate prescribing of pain medication opioids such as hydrocodone, some pundits such as the New York Times make preposterous claims such as “exercise, physical therapy and over-the-counter drugs like acetaminophen can be more effective.”  Those who fantasize that the pain from crushed lumbar disks might be handled with exercise and Tylenol should commit to trying it for a month.

In 2014, there were 29,000 deaths from opioids including heroin.  Opioid deaths occur to just 0.04% of those suffering from chronic pain. Any overdose is a problem, but has not been an outcome for 99.96% of those afflicted with chronic pain.  Note that heroin is not a prescription drug and is never legitimately dispensed.  It should not be a major factor in devising policy for legitimate use of opioids.

For the policy process to have integrity, all of those making opioid policy should have experience as adults suffering from serious chronic pain.  Unless you walk a mile in the sufferer’s shoes you are unlikely to have the compassion and understanding needed to address the issue adequately.  Religious convictions, abstract academic analysis, financial interest in a new pain drug or vote-seeking political biases are entirely unsuited as foundations for setting opioid use policy.  Unlike many newly developed pharmaceuticals, they are affordable to those with chronic pain. There are some new chronic pain treatments in development that sound promising and affordable.

Chronic pain erodes annual productivity (costing $297-$336 billion) and imposes high annual costs for treatment ($261 to $300 billion).  At four tablets per day (a high dosage for most people), the annual cost would range from $204 to $336 for generic Vicodin or generic Roxicodone.  If all 74,000,000 Americans suffering from chronic pain were to use those pain medications, the national cost would be only $15 to $25 billion.  If all 74 million used fentanyl, the cost would be $135 billion. Clearly, the pain treatments in general use are far more expensive than the low cost opioids.

Opioid policy should take advantage of the low cost and effectiveness of opioids on one hand, and, on the other, should restrict access for those who do not need opioids.  Policy should foremost promote the interest of those suffering from pain since the incidence of overdose deaths is too small to dominate policy making. Physicians are in the best position to make that judgment, not politicians.

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