Rethinking use of opioids for chronic pain

There’s no evidence that these medications are helpful

We are very much in the middle of an opioid crisis and the statistics are staggering. One in every eight deaths of young people in this province is attributable to opioids. We have more deaths per year from opioids than we did at the height of the HIV/ AIDS crisis and opioid-related deaths continue to climb in each province and territory. The crisis is being driven by the ever-higher doses being given for chronic pain — conditions such as bad backs, arthritis and pain after car accidents.

And yet, I think it would surprise most people, doctors included, to hear that there is no good scientific evidence to demonstrate that these medications are at all helpful for chronic pain. Unlike other areas of medicine where we subject drugs to high levels of scientific scrutiny for long periods of time, we essentially have no long-term randomized, controlled trials demonstrating the effectiveness of opioids for the treatment of chronic pain.

So how did we get here? The most common explanation in media reports and in medical circles is that we were all just duped. That pharmaceutical companies, and the medical “thought leaders” they paid and promoted, ran very compelling marketing campaigns convincing us that there was an unmet need to treat chronic pain and that opioids including OxyContin were safe and effective for this purpose.

Yet there is another more fundamental and, I believe, more dangerous delusion that we still live under. A delusion that was the grease under the wheels of the pharmaceutical marketing of opioids — that chronic pain is like other diseases that could be fixed by a pill. The answer to pain was simply a “painkiller.” Yet most patients I see at my chronic pain clinic are not coming to see a doctor just because they have pain.

They are coming because they have exhausted their ability to cope with long-standing pain and all the disability we often see with it — like depression, social isolation, insomnia and an ability to work as they previously had. In short, they are seeking help not because they have pain, but because they are suffering.

Part of why opioids have been so unsuccessful for chronic pain is that they are not designed to treat the problem at hand. We don’t need high doses of painkillers. If anything, we need “suffering-killers.”

There is an adage from the tradition of yoga that says “pain is inevitable, but suffering is optional.” In fact, in scientific studies, we can measure pain intensity separately from pain bothersomeness. Interestingly, recent sophisticated imaging studies have demonstrated that pain intensity and bothersomeness are controlled by different parts of the brain. Interventions like breathing practices and meditation have been shown to affect both of these brain networks positively so that they can act both as painkillers and suffering-killers.

As we try diligently as a society to turn the page on the widespread harms of prescription opioids, it is vital that we understand how our delusions about chronic pain, and about our minds and bodies in general, got us here. As we rethink our understanding of chronic pain, we will begin to use safer and more effective treatments more widely while minimizing harmful ones like opioids. Dr. Sud (@doc_sud) is a family doctor and lecturer in the Department of Family and Community Medicine at the University of Toronto. He directs the Safe Opioid Prescribing Program through Continuing Professional Development at the Faculty of Medicine, which teaches doctors how to prescribe opioids for chronic pain in a safer and more evidence-informed manner. Doctors’ Notes is a weekly column by members of the U of T Faculty of Medicine.

In the middle of the opioid crisis, it is vital that we understand how our delusions about chronic pain got us here