Addressing the Opioid Crisis: A Call for Pragmatic Solution
Mark A. Rothstein, Herbert F. Boehl Chair of Law and Medicine, and Julia Irzyk, Advocate for Individuals with Disabilities, call for a compassionate reevaluation of opioid policies, emphasizing the immediate rescission of the CDC’s 2016 guideline to prioritize patient well-being.
Source: The HIll 2021;5:89–102 Published online: April 19, 2021
Title: The opioid crackdown leaves chronic pain patients in limbo
Authors: Mark A. Rothstein, Herbert F. Boehl Chair of Law and Medicine, and Julia Irzyk, Advocate for Individuals with Disabilities.
The opioid crisis, exacerbated since the 1990s, has reached alarming levels with over 100,000 overdose deaths recorded in the 12 months ending April 2021, signifying a 28.5% increase from 2020. Amid the rightful concern for these fatalities, the plight of millions of chronic pain patients struggling to access adequate pain relief often goes unnoticed.
In 2012, American physicians issued a staggering 255 million prescriptions for opioid pain relievers. Efforts to curb the crisis led to a significant reduction by 2020, with only 142 million opioid prescriptions, despite persistently high levels in some regions. Paradoxically, the decrease in opioid prescriptions did not translate into reduced overdose deaths. Instead, deaths surged from 41,000 in 2012 to 100,000 in 2021, primarily attributed to illegal synthetic opioids like fentanyl. The “war on opioids” waged across physicians’ offices inadvertently intensified the suffering of chronic disease patients reliant on long-term pain management.
A pivotal moment occurred in 2016 when the CDC published its “Guideline for Prescribing Opioids for Chronic Pain,” targeting primary care clinicians in outpatient settings. However, its implementation took a problematic turn. The guideline emphasized nonpharmacologic and nonopioid therapy for chronic pain, sometimes leading to ineffective treatments for patients with confirmed injuries and illnesses.
The guideline’s unintended consequences extended beyond primary care settings, as hospitals and large healthcare providers, fearing legal repercussions, drastically restricted opioid prescribing. Over 30 states enacted laws mirroring the CDC guideline, creating additional barriers for physicians treating pain.
Recognizing the guideline’s misuse, the CDC failed to take corrective action in 2019. In 2020, the American Medical Association (AMA) acknowledged the harm inflicted on patients and recommended an immediate suspension of the guideline.
Physicians, guided by the CDC’s recommendation, often engage in rapid tapering of long-term chronic pain patients, contributing to a 68% increase in overdoses and a doubling of mental health crises. Improper tapering also pushes desperate patients to resort to self-medication with heroin or illicit fentanyl, sometimes with tragic outcomes.
Suicides linked to poorly controlled pain may be underreported, contributing to the already alarming figures. A study found that up to 30% of “accidental” overdoses are suicides. Overzealous opioid-limiting policies have especially affected 18 million patients with moderate to severe chronic pain, leading to decreased quality of life.
Policies such as the CDC guideline, Drug Enforcement Administration investigations, prescription drug monitoring programs, Medicare reimbursement policies, and pharmacy and insurance restrictions should undergo comprehensive reevaluation. The CDC, expected to release a revised guideline in 2022, must act urgently to rescind the 2016 guideline, adhering to the fundamental principle of medical ethics: First, do no harm.
Chapter 4 – Wearable Devices in Pain Research: A Paradigm Shift Towards Holistic Assessment
Wearable devices stand at the forefront of revolutionizing pain assessment, offering a profound understanding of physiological responses and temporal dynamics. The intricate interplay between pain and the autonomic nervous system highlights wearables’ potential to objectively capture the timing and intensity of pain episodes. While direct correlations between pain scores and wearable sensor data are limited, 16 identified studies since 2015 provide crucial insights.
Comparative studies between individuals with pain and healthy counterparts reveal nuanced activity patterns without clear associations with pain scores. Intervention studies, employing combined behavior and wearable strategies, yield mixed results, emphasizing the condition-specific effectiveness of such approaches.
Moving beyond physical activity, the integration of biosignals and Ecological Momentary Assessment (EMA) data emerges as a promising avenue to unravel the temporal patterns of chronic pain. Exploring the intricate relationship between sleep and pain, facilitated by accelerometers, adds another layer of understanding. The current separation of sleep and physical activity studies calls for integrated efforts to grasp the multidirectional causal relationship between pain, activity, and sleep.
In summary, the future of pain research with wearables involves expanding the scope of physiological measures, integrating diverse data sources, and gaining a comprehensive understanding of pain’s multifaceted relationship with physiological responses. This evolution promises to redefine pain assessment, ushering in a new era in patient care and research methodologies.
Expanding on the transformative role of wearables, the integration of various biosignals offers a deeper exploration of pain physiology. Accelerometry, while valuable, requires augmentation with physiological signals, such as heart rate variability (HRV), to enrich pain assessment. Recent studies showcasing the predictive potential of wearables during sickle cell pain crises underscore the importance of delving into biosignals associated with pain.
Beyond physical activity, the integration of diverse biosignals paves the way for objective pain endpoints. Early prediction of pain crises, reminiscent of predictive models in cardiology, emerges as a significant opportunity. Patient-centric studies, where individuals act as their own controls, become imperative, considering both pain and pain-free periods. Harmonizing wearable use with Ecological Momentary Assessment (EMA) data collection presents challenges, necessitating meticulous consideration of device parameters and questionnaire design.
Etiological classification (nociceptive, neuropathic, nociplastic) becomes a guiding principle, aiding researchers in identifying promising biosignals tailored to specific pain conditions. Conceptual challenges involving the complex interplay of pain, activity, and interventions underscore the need for just-in-time adaptive interventions. Standardizing visualizations and widgets ensures comparability and opens avenues from tracking historical trends to real-time personalized interventions.
Methodologically, challenges persist in handling high-dimensional, correlated wearable data. Multidimensional measures, amalgamating subjective and objective data, hold promise for clinical application and research outcomes. Bridging the transition from research to clinical practice gains momentum by offering patients valuable feedback and just-in-time adaptive interventions. The future envisions enhanced patient care, understanding pain in real-world scenarios through the amalgamation of wearable technologies and EMA. This holistic approach promises to redefine the landscape of pain research and patient-centric methodologies.
