In the year 2017, a plethora of articles and commentaries on the “opioid crisis” have appeared in major medical journals, alongside the ongoing hyperbole seen daily in the lay media. But the pressing concern remains: How best to manage patients who are 1.) already taking opioids and 2.) those newly requesting relief of serious and chronic pain.
Opioid for Pain and Its Misuse
In this article by Volkow and Collins, both of whom are titans in neuroscience, we are reminded that despite all the warnings, opioids are being widely prescribed in the U.S. In a weighted national sample of over 50,000 adults, the investigators concluded that more than one-third of the adult population has taken an opioid at some point during 2015. Among these, 12.5% confirmed that they misused the drug, e.g., used them without a prescription or in any way contrary to the prescribed directions. Of these, 16.7% developed an opioid-use disorder, as defined in the DSM-IV.
In response, Volkow and Collins note that an increasing number of clinicians are attempting to control chronic or intractable pain with new anticonvulsants such as Pregabalin (Lyrica) and Gabapentin. Yet, these drugs have only been shown to be effective only for fibromyalgia and certain forms of neurogenic pain. In addition, the authors note that a multidisciplinary workgroup convened by the NIH Office of Disease Prevention (2014) found that there had been no randomized trials to evaluate the efficacy of long-term (>1 year) opioid treatment. Accordingly, the authors recommend short-term strategy to develop abuse-deterrent formulations that can minimize diversion and misuse.
What About Cannabis?
In a 2017 report from the National Academies of Sciences, Engineering, and Medicine, substantial evidence supports the effectiveness of cannabinoids in treating some types of pain. However, again there is scant research on phytocannabinoids as medicine. In addition, there are abundant research and legitimate concerns related to cognitive, motor and motivational impairment and the effects on brain development. However, the therapeutic potential of cannabinoids and mediators of the abundant endocannabinoid system warrants further exploration for alternatives to opioids.
Lastly, non-pharmacologic interventions, including behavioral, self-management interventions, may play an important role in pain management. The initiative described by the authors supports partnerships between the NIH and pharmaceutical and biotechnology companies to hasten medication and device development.
Why Does This Matter?
If these data are true, and one-third of the U.S. adult population suffers from chronic pain, we are duty bound to find therapeutic options with less risk, addictive potential and mortality. As I have argued for nearly 40 years, basic and translational research is desperately needed, as clinicians are in a conundrum between the worthy goals of alleviating pain and suffering and decreasing the risk for addiction and mortality. We can, and must do better.