In 1990, Ronald Melzack published a paper in Scientific American titled “The Tragedy of Needless Pain.” Many would regard Melzack as the “father” of pain science and the treatment of pain. In that paper, he described the science behind several observations that many clinicians and public health policy decision-makers would find startling in today’s hostile and fraught regulatory environment surrounding the U.S. opioid crisis.
… the fact is that when patients take morphine to combat pain, it is rare to see addiction — which is characterized by a psychological craving for a substance and, when the substance is suddenly removed, by the development of withdrawal symptoms (for example, sweating, aches and nausea). Addiction seems to arise only in some fraction of morphine users who take the drug for its psychological effects, such as its ability to produce euphoria and relieve tension.
Furthermore, patients who take morphine for pain do not develop the rapid physical tolerance to the drug that is often a sign of addiction. Many people who are prone to addiction quickly require markedly escalating doses to achieve a desired change of mood, but patients who take the drug to control pain do not need sharply rising doses for relief. They may develop some tolerance initially, but their required dose usually rises gradually and then stabilizes.”
Study after study of patients whose pain is most often treated with narcotics — namely, cancer patients, burn victims, and those hospitalized for surgery — has shown that the patients who develop rapid and marked tolerance to, and dependence on, the narcotics are usually those who already have a history of psychological disturbance or substance abuse.
Over the past 33 years, clinical understanding of pain has evolved. We now understand that withdrawal symptoms are a predictable physiological reaction to rapid tapering after prolonged use of opioids. But dependence is not the same as addiction, despite the two having been historically confused.
The highly definitive VA’s Stratification Tool for Opioid Risk Mitigation (STORM) predictive model has demonstrated that, as Melzak informed us, the best predictor of opioid overdose or suicide in clinical patients is a past history of severe mental health issues, alcoholism, or drug abuse. Among post-surgical patients prescribed opioids for pain, addiction is quite rare. The frequency of surgical patients being continued on prescriptions is less than 1 percent and is primarily a reflection of failure rates of surgery. Rates are lowest for Caesarian section and highest for total knee arthroplasty.
Addiction as an outgrowth of clinically managed opioid therapy is both extremely rare and unpredictable at the individual level. We also understand why it is rare and unpredictable.
- The minimum effective morphine equivalent dose is highly variable between individuals because of genetic polymorphisms underlying six key liver enzymes that moderate opioid metabolism (CYP-450 series).
- People with addiction are almost entirely distinct from clinical patients treated for pain. The typical patient who regularly sees a doctor for pain is a woman of middle age or older who has health insurance. Patients whose lives are stable enough to support an ongoing doctor-patient relationship are almost never addicted. On the other hand, the typical person suffering from addiction is a male with less than a high school education, in chronic physical pain (often from occupational injury), burdened with serious mental illness, and typically living in relative isolation with very limited access to health care services.
The benefits of pain treatment with opioids can be assessed in the course of a clinic visit. But the “risk” of opioid addiction as a possible future outcome of treatment cannot be predicted — partly because it is infinitesimal. There are no validated clinical risk profiling instruments that offer predictive accuracy. This reality is acknowledged even in the otherwise fatally flawed 2022 updated Centers for Disease Control and Prevention (CDC) practice guidelines for opioid prescribing.
The U.S. is weathering an “opioid crisis.” However, it is clear that clinicians prescribing opioids for patients in pain are not a significant contributor. Drug-related overdoses have increased exponentially over the past 40 years. But prescriptions are only one of seven factors contributing to that increase. Since pill mills were shut down from 2010 to 2012, mortality has been overwhelmingly associated with illicit fentanyl use. Recent analysis demonstrates that CDC claims of a cause-and-effect relationship between opioid prescribing and overdose deaths are false.
As Melzak notes, “Society’s failure to distinguish between the emotionally impaired addict and the psychologically healthy pain sufferer has affected every segment of the population.” Indeed, our present opioid “crisis” is not one of medical exposure. It is instead an outgrowth of conditions in which people live. It is a crisis of hopelessness driven by fear, desperation, and anxiety – not a crisis driven by medical supply.
Pain medicine in America has been criminalized by misinformation published by the CDC and massive over-regulation by the Department of Justice. Clinicians are no longer permitted to be compassionate for fear of Drug Enforcement Agency or state medical board sanctions. Restrictions on patient access to safe and effective opioid therapy have had no measurable positive effect on the real crisis of hopelessness — and will not in the future. Such restrictions only worsen the tragedy of needless pain, medical collapse, and patient deaths by suicide. Since the publication of the 2016 CDC guidelines, opioid-related mortality – 90 percent from illicit drugs – has more than doubled.
Richard A. Lawhern is a patient advocate. Stephen E. Nadeau is a behavioral neurologist.