PAINWeek Keynote Address: Balancing Exposure and Addiction

In the opioid pendulum, where are we now: between opiophilia and opiophobia?
In the opioid pendulum, where are we now: between opiophilia and opiophobia?

LAS VEGAS—The public health system in the United States is facing 2 major issues: the opioid epidemic and the less-publicized chronic pain epidemic, according to a presentation at PAINWeek 2016. 

“Treating pain can be a very isolating experience,” Steven Passik, PhD, said during the keynote lecture at the meeting.1 Dr Passik is currently senior director at Endo Pharmaceuticals; he formerly served as faculty at Vanderbilt University in Nashville, Tennessee, and Memorial Sloan Kettering Cancer Center in New York City.

Dr Passik added that the task of pain management professionals has been rendered difficult by society's perception of opioid prescribing.

According to Dr Passik, there are main issues at hand are chronic pain and opioid overuse, abuse, diversion, overdose, and death. “We have to solve [these] for the good of our patients,” he added. Unfortunately, in the wake of the US Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain published in March this year,2 many clinicians may start thinking that opioids are ineffective and may as a result hesitate to treat patients with pain.

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Dr Passik proposed taking a different approach, using research showing success stories following changes in opioid use. He pointed to North Carolina, where opioid overdose deaths have decreased by 70% without “putting downward pressure on opioid prescriptions.”3

Prescription opioid abuse is very costly; 16,000 to 19000 overdose deaths occur every year and $20 to $120 billion is spent per year. In addition, 25 to 39 million people experience daily chronic pain and 10 million are disabled due to pain. 

“We have 2 big epidemics and we have 2 problems; we need to solve those problems, and we need to do it with complex public health solutions, better drugs, and better practice,” Dr Passik explained.

It is imperative to determine which subsets of patients on long-term opioid treatment are likely to develop a problem after a year of stable dose of opioid therapy. “We have to figure out who those patients are, because with judicious use of opioids, with pain relief and patient safety in mind, [opioid treatment] is appropriate," Dr Passik said.

No single treatment option should be first line for everybody, but “we are treating it as if the drugs are the sole cause of the problem: if we cut down exposure, we will cut down deaths and addiction. Addiction is not a disease of exposure. Exposure is necessary but not sufficient to create drug addiction.” Dr Passik concluded that the emphasis should be on raising the standard of care, not on limiting opioid exposure.

References

  1. Passik SD. X: It is not what you think. Presented at: PAINWeek 2016. Las Vegas, NV; September 6-10, 2016.
  2. Dowell D, Haegerich TM, Chou R. Guideline for prescribing opioids for chronic pain — United States, 2016.MMWR Recomm Rep. 2016;65:1-49. doi: http://dx.doi.org/10.15585/mmwr.rr6501e1M2016.
  3. Medication and drug overdoses – North Carolina. North Carolina Department of Public Health. Available at: http://injuryfreenc.web.unc.edu/files/2014/07/Data-Overview-071414.pdf. Accessed September 8, 2016.

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