While most Americans are aware of the United States’ ongoing opioid epidemic, many are not aware of the related, similarly disturbing, and unsolved epidemic of chronic pain. According to the most recent epidemiological evidence, over 100 million Americans suffer from some form of chronic non-cancer pain or CNCP (Ahrnsbrak et al. 2017: data from 2016 National Survey on Drug Use and Health; Furlan et al., 2006). Of the CNCP population, more than 10 million patients have been prescribed long-term opioid therapy for pain and disability management, despite an emerging consensus of ineffectiveness and a lack of evidence for long-term use (Volkow & McLellan, 2016; Saidi et al., 2018; Shaheed et al., 2016; Eriksen et al., 2006; Moulin et al., 2015; Manchikanti et al., 2011). Approximately 25% of these CNCP patients misuse their opioids, with between 8-12% developing an opioid use disorder (Muhuri et al., 2013, Cicero et al., 2014, Vowles et al., 2015).

10 million
Americans have been prescribed long-term opioid therapy for chronic pain
44%
Nearly half of chronic pain patients report hazardous drug-related behavior.
23.7%
Fewer than 1/4th of neuropathic pain patients have significant reductions in pain and disability with opioids.

Every day in the US, on average, over 115 people die due to opioid overdose, with 42,249 deaths in 2016 alone (https://www.cdc.gov/; https://www.drugabuse.gov). The origins of contemporary North American opioid abuse can be traced back to the clinic; multiple research papers indicate that greater than 75% of heroin abusers reported that their first opioid was a prescription drug (Cicero et al., 2014; Muhuri et al., 2013; Jones et al., 2013). Moreover, more than half of adults undergoing medication-assisted therapy (such as methadone maintenance) during rehabilitation for opioid use disorder have coexisting chronic pain, demonstrating sizable overlap between these two cohorts (Dunn et al., 2014).

A 2008 study of the Medicaid population found that greater than 50% of opioid prescription are for high amounts (>90 MME) and for periods longer than six months. With a reported 44% of chronic pain patients reporting hazardous drug-related behavior and up to 18.9% of CNCP patients exhibiting substance abuse disorders, these prescriptions likely only further the size and scope of the opioid crisis (Katz et al., 2007; Passik et al., 2006; Rosenblum et al., 2008).

While a minority of CNCP patients may benefit from long-term opioid therapy, the majority of patients see more harms than benefits (Saidi et al., 2018). In Saidi & peers’ study, 63% of a cohort of 893 CNCP patients who began opioid therapy stopped because of a lack of pain relief and/or adverse effects (Saidi et al., 2018). A 2015 study found that only 23.7% of chronic neuropathic pain patients saw significant reductions in pain and disability with 1 year of opioid therapy and only 32.4% of the patients receiving clinically significant pain relief (Moulin et al., 2015). Patients in this study on long-term opioid therapy reported lower mental and physical quality of life measures than those who ended their opioid-therapy and those who never began it. In a systematic review and meta analysis of 20 randomized-controlled trials, Shaheed & colleagues found opioid therapy demonstrated evidence of modest efficacy for short-term use, but there continues to be a lack a data supporting long-term opioid therapy (longer than 3 months) for chronic lower back pain (Shaheed et al., 2016). Eriksen & colleagues summarized the state of long-term opioid treatment for CNCP by saying “…[O]pioid treatment of long-term/chronic non-cancer pain does not seem to fulfil any of the key outcome opioid treatment goals: pain relief, improved quality of life and improved functional capacity.” (Eriksen et al., 2006).

The medical and patient communities urgently need a new standard-of-care medication for long-term chronic pain. By prescribing desperate and suffering patients a long-term, addictive, and ineffective painkiller that requires larger and larger doses for the same relief over time, pharmaceutical companies and the healthcare system have created the perfect storm for opioid abuse. What has emerged is a population of dependent or addicted individuals, most of which do not get the relief they need, who may turn to illegal and cheaper alternatives. Long-term opioid therapy has wasted CNCP patients and insurance companies billions of dollars on ineffective treatment, fanned the flames of the opioid epidemic, and ruined or ended tens of thousands of lives in the process.

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If you or someone you love is afflicted with chronic or refractory pain, and/or if they’re opioid-dependent, please don’t hesitate to reach out to discuss enrollment in one of our trials or treatment programs.

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References

Dunn, K. E., Brooner, R. K., & Clark, M. R. (2014). Severity and interference of chronic pain in methadone-maintained outpatients. Pain Medicine, 15(9), 1540–1548. http:// dx.doi.org/10.1111/pme.12430

Ahrnsbrak, R., Bose, J., Hedden, S. L., Lipari, R. N., & Park-Lee, E. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration: Rockville, MD, USA.
Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826.

Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1-2):95-100.

Muhuri PK, Gfroerer JC, Davies MC; Substance Abuse and Mental Health Services Administration. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review. http://www.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.pdf. Published August 2013. Accessed October 8, 2015.

U.S. Census Bureau (2017)

Volkow, N. D., & McLellan, A. T. (2016). Opioid abuse in chronic pain—misconceptions and mitigation strategies. New England Journal of Medicine, 374(13), 1253-1263.
Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006;174(11):1589-94.

Saïdi, H., Pagé, M. G., Boulanger, A., Ware, M. A., & Choinière, M. (2018). Effectiveness of long-term opioid therapy among chronic non-cancer pain patients attending multidisciplinary pain treatment clinics: a Quebec Pain Registry study. Canadian Journal of Pain, 2(1), 113-124.

Shaheed, C. A., Maher, C. G., Williams, K. A., Day, R., & McLachlan, A. J. (2016). Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis. JAMA internal medicine, 176(7), 958-968.

Eriksen, J., Sjøgren, P., Bruera, E., Ekholm, O., & Rasmussen, N. K. (2006). Critical issues on opioids in chronic non-cancer pain:: An epidemiological study. Pain, 125(1-2), 172-179.

Moulin DE, Clark AJ, Gordon A, Lynch M, Morley-Forster PK, Nathan H, Smyth C, et al. Long-term outcome of the management of chronic neuropathic pain: a prospective observational study. J Pain. 2015;16 (9):852–861. doi:10.1016/j.jpain.2015.05.011.

Laxmaiah Manchikanti, M. D., Hary Ailinani, M. D., Dhanalakshmi Koyyalagunta, M. D., Sukdeb Datta, M. D., Vijay Singh, M. D., Ike Eriator, M. D., … & Rinoo Shah, M. D. (2011). A systematic review of randomized trials of long-term opioid management for chronic non-cancer pain. Pain physician, 14(1), 91-121.

https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
(https://www.cdc.gov/drugoverdose/epidemic/index.html)
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Rosenblum, A., Marsch, L. A., Joseph, H., & Portenoy, R. K. (2008). Opioids and the treatment of chronic pain: controversies, current status, and future directions. Experimental and clinical psychopharmacology, 16(5), 405.

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