One of the challenging issues for an editor is to come up with an interesting and timely issue. As a consumer of health information, and someone with a vested interest in the pain and palliative care fields, you obviously are aware that the topic of opioid pharmacotherapy continues to dominate news headlines. It seems a day does not go by where there is not a news story that involves opioids or the use of naloxone. To some extent this is not surprising, opioid analgesics have long been considered controversial. In my own career I have seen the pendulum swing with respect to the accepted clinical application of opioid analgesics. In my early pharmacy training in the 1980s opioid analgesics were discussed only in the context of severe acute pain and advanced cancer pain. As I completed my fellowship training in the late 1990s, the pendulum was swinging in favor of the use of opioid analgesics for patients with chronic non-cancer pain. As we enter 2019 it seems as though the pendulum has swung to a point where even use in severe acute pain and in palliative care is now in question.
This is fascinating in many respects, as opium extracts for medical and recreational use dates to antiquity. In this regard it has long been known that these agents have potential for not only treating pain but can also be used for non-medical purposes. This duality is, I believe, at the heart of our problem as we move into 2019. Those that work with patients in pain look at the potential viability of opioid based pharmacotherapy for a subset of patients. These patients include some of the most vulnerable in our society, including those who are dying. At the same time, there are individuals and institutions that are dealing with the significant issue of illicit drug use and opioid associated deaths. These negative outcomes and issues have been a significant component that is part of our current debate about the potential role and value of opioid based pharmacotherapy.
The problem that I perceive is that our society craves information, and the more sensational the story the more interest this generates. I am fully cognizant that modern society faces two equally important issues, but the focus in the popular media seems fixated on issues that generate instant interest and connection with its consumers. This is difficult, as the truth that exists in this narrative does resonate with me as a clinician and scientist. Our modern society does have a substance abuse problem, and opioid substances are certainly a big part of this problem. At the same time our modern world is also dealing with a pain crisis that is not being adequately addressed. These competing interests don’t necessarily need to compete against each other. Should opioid analgesic use be as widespread for the management of pain as it was in the recent past? The obvious answer is no. At the same time there are many clinicians that believe there exists a set of patient populations where use of an opioid analgesic can be appropriate. Within these populations we need to be vigilant that opioid analgesics are used for patients where there is documented utility. At the same time, we also need to explore how to most appropriately interpret the current evidence base with respect to opioids. I believe this last point remains an area of contention that should be discussed in an open and rational manner. This is, at least in part, the consequence of media hype and misinterpretation of data points associated with the larger domain of opioids. That is to say an opioid in various reporting systems isn’t exclusive to those prescribed for analgesia. In recent years illicit fentanyl use has sky rocketed. This and other illicit sources are often combined with data from legal, and potentially appropriate, prescription opioids. This approach is unfortunate as it does not provide an accurate reflection of this issue.
This brings us to today, and the discussion of how move forward to promote an environment of scientific balance and patient advocacy. I believe there are many well intentioned individuals that have been led astray by looking only at superficial aspects of this difficult circumstance. This includes individuals on both ends of this continuum. I firmly believe we need to reexamine how we explore this very complex topic. This includes both addressing issues related to proper provision of pain management, but also addressing how to best deal with our current problem with substance abuse. Of course, these issues are not completely exclusive to one another, which is another area for investigation and exploration.
With respect to the issues of data management and reporting, a larger and more germane discussion should focus on how best to implement pharmacotherapy for patients with pain. This discussion should encompass the potentially limited capacity for benefit that any drug therapy might play for a specific patient. I am reminded of my roots in pain management, where I was first introduced to the concept of an interdisciplinary approach to managing pain. In our clinic we considered pharmacotherapy, inclusive of opioid analgesics, as part of a larger treatment paradigm that included physical and behavioral medicine. For many patients the use of pharmacotherapy was a bridge that enabled these patients to benefit from the therapies offered by colleagues in physical therapy and mental health. We enjoyed great success with our patient population using this approach. We all know there remain significant limitations to this type of care, but I suggest we need to find ways to make this the norm moving forward. Until this becomes standard practice, I hope we can find a way to encourage clinicians to be holistic and consider the real value of an analgesic substance in managing their patients.
Have a great 2019!
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