I was a bit annoyed by this article that appeared on The Age website and was retweeted widely. The title -_ Opioid addiction: Treatments get people off painkillers, but it is a hard road_ - suggests the story is about prescription opioid addiction.
The body of the piece then sets out the familiar narrative (to me at least) that current prescribing trends in Australia are not yet following the best available evidence for treatment of persistent pain. Too much opioid prescribing, too little investment in pain services which can provide a flexible, comprehensive response to the problem.
The patient described in the piece does not sound like he was addicted to opioids. He sounds far more typical of the majority of opioid users with persistent pain. He was taking the drugs rationally and as prescribed, in an attempt to improve his pain. He was experiencing cognitive and other side effects that are common at high doses.
When offered a better option, he weaned himself off the useless medication under supervision and now has less sedation and more skills to self-manage his pain.
I get really frustrated when stories like this are portrayed as a heroic battle against addiction. They are not. It is lazy or cynical journalism to say so. Ceasing opioids is an end in itself if one is treating an addiction. It is not necessarily an end in itself if you are treating persistent pain. Intelligent reporting would not confuse the two.
The real story is that the evidence has changed and pain clinicians no longer think there are manageable consequences to high-dose prescribing. We also recognise that there are a number of much more effective therapies to help people manage their pain. There are plenty of reasons people do better when they see a pain service that takes a comprehensive approach to the problem of chronic pain.
To start with, there are sometimes relatively little-known but treatable conditions such as soft-tissue pain in the neck and back of the hip. I see a few of these each week and they usually do very well once the problem is adequately recognised.
In addition to a clearer diagnosis, expert care can target medications more rationally based on the mechanism of the pain, rather than purely the diagnosis. Using antidepressant medications for diabetic peripheral neuropathy pain seems counter-intuitive but can be very effective.
Interventions such as nerve blocks and injections can be a useful circuit-breaker to enable better participation in an overall rehabilitation program. Occasionally they work so well no further treatment is needed, but no pain clinician worth their salt would contemplate using them as the whole treatment most of the time.
Newer, more high-tech and invasive therapies such as neuromodulation devices, are offering genuinely exciting potential for impressive individual results. Here is an example from my colleague’s practice of a desperate situation improved by expert care.
Training in the cognitive skills and emotional adaption required to put them into practice is labour-intensive and requires a dedicated allied health team. The evidence supporting the effectiveness of multidisciplinary pain care is as good as any of the more medically-driven treatment.
Remuneration and referral patterns don’t reflect this fact. In truth, you don’t get the best results without milking every part of the team for all they can give. You never know which team member may hold the key to unlocking the biggest gains for any given patient.
Media reporting of the retreat from opioid prescribing for persistent pain should not focus on saving people from addiction, but should emphasise the more positive story, which is that we are seriously improving the care we can offer people with chronic pain.
Casually referring to the silent majority of pain sufferers taking medications as they are meant to as “addicted” does nothing to further the discussion. Using complicated social and medical problems as clickbait is not just lazy journalism but adds to the everyday stigma surrounding persistent pain and its treatment.