By Albert Ray, MD

Over the years, confusion and misinformation surrounding the use of opioids — commonly known as narcotics — has contributed to the already significant problem of under-treating pain in the more than 70 million Americans who live with it daily. Most recently, a national news media report on federal drug prescription data concluded that retail sales of five commonly prescribed pain medications have almost doubled over the last eight years. While attention-grabbing, these kinds of reports do not provide the full story about the role of pain medication in treating chronic pain.

In fact, the increase in pain medication usage is due to several factors, including

• a trend to reversing the under-treatment of pain,
• more research and improved scientific understanding of pain as a disease,
• increased awareness and education about how to properly treat pain, and
• advances in pharmaceuticals.

Under-treatment or Poor Treatment

For many years, both the medical community and the public feared that the use of pain medications would lead to massive amounts of addiction in patients. As a result, patients most often were under-treated or not treated for pain. They were told to "be strong and bear it." This poor treatment resulted in much needless suffering for our patients. More and more health professionals now understand that pain must be treated to improve function and quality of life in those who live with chronic pain conditions.

Research

Pain research over the last 20 years has now shown us that under-treated pain can lead to pathological changes in the nerves (the peripheral nervous system) and the spinal cord and brain, which make up the central nervous system. These changes result in pain becoming a chronic disease, with consequences such as

• long-term pain,
• increased levels of pain and disability,
• decreased ability to concentrate and difficulty with memory,
• significant levels of depression and anxiety,
• inability to function at home or work,
• poor sleep, and
• an increase in other problems such as irritable bowel syndrome, headaches, and fibromyalgia, all of which tend to become chronic problems.

The medical community is now aware of the importance of treating pain properly and aggressively to reduce or prevent these negative consequences on a person's life.

Another factor that research has shown is that most patients — if they use their opioid medications properly — will never become addicted to them. Most individuals who have problems with medication addiction have a genetic propensity to become addicted, already had an addictive disorder, or both.

The brain of a person who has an addictive disorder or the potential for such a disorder reacts differently to opioid medications than someone without such issues. In other words, the brain centers in addicted individuals process medications differently. Because of this, we now understand that addictive disorders are neurobiological disorders — meaning they are biological in nature. Psychological and social factors are secondary problems in addiction.

Consequently, the concern about becoming addicted is more problematic for someone who has been or presently is addicted to substances and for those who have a family history of alcohol or other substance abuse. In these cases, people may still benefit from medications for pain control — they just require more complex treatment by a multidisciplinary team.

Awareness and Education

The National Pain Foundation and multiple other organizations have devoted their efforts to raising awareness of pain and its consequences. This effort has led to better education among the medical community and the public in general, and people now have a place to go to learn about their pain and the options available for treating their pain — www.NationalPainFoundation.org. Medications are just one piece in the proper treatment of pain, but medications were unjustifiably being feared and underutilized.

The other result of efforts at raising awareness and improving quality of pain care for Americans brought the US Congress to declare 2000 to 2010 the Decade of Pain Care and Research. This enables researchers to obtain more money for scientific studies on pain, further improving our medical knowledge about pain.

Pharmaceutical Advances

Most of the older short-acting opioid pain medications have a greater propensity to cause addiction. Therefore, many pharmaceutical companies have worked at creating longer acting medications which tend to reduce the potential for addiction.

These companies are also working diligently to design ways to make medications more difficult to abuse, so that even someone who crushes opioids cannot get "high." This is difficult to accomplish, but it is the goal of the companies who produce these medications. Their goals are to create safe medications that adequately relieve pain and, at the same time, reduce the possibility of addiction and abuse.

A Multidisciplinary Approach to Treating Pain

The specialty of pain medicine encompasses many different experts and an arsenal of treatments and approaches. Opioids can be an effective weapon against pain; however, the over-the-top fear mongering about addictive pain medicines often keeps patients from seeking help and prevents primary care medical providers from referring people with chronic pain to pain specialists. Some of the proven medications, procedures and techniques to treat pain, in addition to opioids, include:

• non-opioid pain medicines, such as anti-depressants, anti-convulsants, and non-steroidal anti-inflammatories,
• neuromodulation methodologies, including electrical stimulators for the nervous system and implanted medication pumps which deliver preset amounts of medications directly to the nervous system,
• physical therapy,
• ice or heat,
• massage,
• acupuncture, and
• behavioral and psychological treatments that directly alter the way a person's brain processes pain information.

Some pharmaceutical companies produced medications that have proven pain-relieving effects without any connection to opioids (eg, anti-convulsants, anti-depressants). Some of these medications have proven to be as useful or more useful than opioids in certain types of pain. These medications, then, are useful for pain control without any fear of addiction.

Neuromodulation techniques include electrical stimulation of the nervous system to reduce pain directly and implanted medication pumps that allow for various types of medications to be used without fear of abuse as the system is programmed to avoid abuse.

Much of chronic pain also relates to "soft tissue" problems, which includes the muscles, tendons, and ligaments. Physical therapy techniques which teach proper stretching, strengthening, posture, movements, and efficiency of the body are extremely important to reduce any pain related to soft tissue problems, and have been shown to affect even some central nervous system problems.

Learning how to interpret pain differently and how to respond to it differently can markedly reduce a person's perception of pain. This is one value of behavioral treatments for pain. For example, a psychological treatment called Eye Movement Desensitization and Reprocessing (EMDR) has been shown to be very effective in treating phantom pains, which are a result of a brain dysfunction. EMDR has been shown to markedly reduce or eliminate phantom pain by changing how the brain processes information. Some integrative treatments such as biofeedback, acupuncture, yoga, self-hypnosis, and others also offer a significant change in pain intensity as well as help patients cope better with their pain disease.

Summary

We believe the increased use of pain medications is due to a greater awareness of the serious and significant problems caused by NOT treating pain adequately, increased medical knowledge from research into pain, and an increased awareness by the medical community and the general public as to what pain is about and what is available to treat it properly and adequately.

The National Pain Foundation (www.NationalPainFoundation.org) remains committed to reducing suffering by raising awareness of pain, its consequences, and available treatments and providing reliable information for patients and family members. Contact us at anytime, and tell your friends that we are here for those who live with pain and their loved ones.

Albert Ray, M.D., chairman of the National Pain Foundation, is past president of the American Academy of Pain Medicine and the medical director of the Miami Pain Medicine Center. He is a diplomat of the American Board of Pain Medicine.