A February 2016 study published in JAMA Internal Medicine found that, contrary to how the genesis of the opioid crisis has been framed in the public eye, the overprescription of painkillers is not the fault of a small number of physicians, but rather a widespread issue that needs to be addressed by healthcare stakeholders as a whole. James Campbell, MD, founder of the Johns Hopkins Blaustein Pain Treatment Center in Baltimore, is one expert who believes the problem is far more complex than there being certain breeds of prescription-happy physicians.
Although more eyes are turning toward the crisis, patients have been wrestling with chronic pain — and physicians with how to treat it — for decades.
"This is something that really is not brand new," Dr. Campbell says. "People in our country and around the world are in chronic pain."
The crisis is rife with challenges, Dr. Campbell says, from weaning patients off opioids after the medications have run the course of treatment, to addressing the growing threat of powerful street drugs, such as fentanyl and heroin, which addicts commonly turn to after coming off of prescriptions from physicians.
Little about the problem is clear cut, but a multifaceted response that includes offering better education for physicians on prescription behaviors and a shifting attitude about the treatment of addiction are without a doubt part of the solution, Dr. Campbell says.
The search for other pain management solutions led Dr. Campbell to his current position as co-founder, president and chief scientific officer of Baltimore-based Centrexion Therapeutics, which is working to develop alternative treatments for pain.
"At the moment we have physicians playing a role in inadvertently feeding drugs in the system that's causing this crisis, but there are dangers in telling them to just stop writing prescriptions for the many patients who will benefit from the drugs," Dr. Campbell says. "I really feel that the future must involve the development of new treatments for pain."
Dr. Campbell spoke with Becker's Hospital Review about how the crisis became a crisis, what physicians can do, and what the future of pain management might look like.
Editor's note: Responses are lightly edited for length and clarity.
Question: How did we get to the point where our country is facing an opioid crisis?
Dr. Campbell: The crisis is two-fold. On one hand, chronic pain is a really major U.S. public health problem. As baby boomers get older, the pain problem simply increases. On the other hand, doctors are increasingly told to be sensitive to their patients, to be humanistic to their patients, to ask about their level of pain. So when you have a population in chronic pain that indicates they're in pain — what do you do about it?
And there the opioids present a conundrum. They help some people. But there's a minority of people — we don't know what that number is, it could be 5 percent, it might be 10 percent or an even greater number — who develop this addiction syndrome. Then there's the issue of diversion. Even if a patient is taking opioids responsibly there may be young people in the home who are tempted to experiment with the drugs or divert the drugs in other ways. The pills may have street value and we have physicians feeding medicines into the drug culture and we see the consequences and ravages of that.
But I think from a pain advocacy perspective, all of this is predicated on patients having pain. Independent of medications and prescriptions, when epidemiological studies are done, here are the kinds of numbers we come up with: One in three Americans have a problem with chronic pain. A recent study from the National Institutes of Health indicated that 10 million Americans have a lot of pain on a daily basis. These are staggering numbers, and regardless of where one stands about how opioids should be used, we can all agree they are much less than ideal. They carry problems beyond addiction, such as very powerful side effects.
Q: Why has the focus on opioids and addiction grown so much in the last year?
Dr. Campbell: The answer is I'm not entirely sure. The numbers have been creeping up in terms of accidental overdose. Some of that is connected with other factors, for example, very inexpensive heroin. Fentanyl is an ultra-potent opioid that's newly available on the street, and so the drug trade has come up with ways to lace the heroin or just give out fentanyl. The issue with these drugs is, compared to a pill patients might be familiar with, someone wrestling with addiction who gets drugs off of the street has no idea what they're getting.
One initiative to help save people is increasing access to naloxone, an otherwise harmless drug that can be lifesaving when given to someone who has overdosed on opioids, making it widely available in the context where one might see a drug overdose.
Another major factor is realizing that addiction is something more than just a moral breakdown. There are probably some genetic factors that go into this, and addiction is best treated in a medical model. We do not adequately address addiction problems in terms of access to care for patients who need help.
Q: What are your recommendations for physicians?
Dr. Campbell: The educational process would be to make them more aware of the different options that can be pursued for the patient, to enact a system where a patient only tries using an opioid after carefully thinking through their options and ensuring they understand the risk. There are numerous red flags, and we need to learn more about recognizing these and then transmit that information on an educational basis to the primary care doctor. On a short term basis, that can help address the crisis.
Quite often these medications work at first but then the patient builds a tolerance, which leads to increasing the doses and running into more side effects. It spirals out of control and suddenly you have a patient taking high doses of opioids. The majority of patients don't have addiction issues, they don't like the opioids but they become physically dependent and then the physician has to figure out how to deal with that dependency.
The major role that I have adopted is doing what I can to nurture the development of new therapies. A lot of my work right now is to talk with scientists and academics about the importance of doing everything that we can to develop new treatments. These things at the moment are not of any practical value to the primary care doctor, who Wednesday afternoon at 2 p.m. sees a patient with chronic low back pain for which there is no surgery available. What do they do about that patient? That is a conundrum, but there is this important educational process that we can more vigorously encourage doctors to pursue.
Q: Do you think the opioid crisis will have a lasting effect on how physicians help patients manage pain?
Dr. Campbell: Regardless of whether we come up with the solution for the patient, a doctor can always offer understanding and comfort to their patient, and I think the awareness of the pain problem and not just sweeping it under the rug is a very essential part of the doctor-patient relationship.
We have to see our patients' pain for what it is. If someone has cancer, even if it's untreatable, we diagnose and help the patient determine a prognosis and do the best we can to comfort the patient and guide the decision-making. Just because a disease is tough to treat doesn't mean we ignore it. So I think the message is to provide humane care, to thoughtfully think through the options for patients without automatically writing a prescription for an opioid. The use of opioids needs to be much more thoughtful, and there has to be very careful follow-up of patients. Everybody — doctors, patients and policymakers — should be screaming for us to come up with new treatments. That's what we as a society have fallen short on — coming up with new advances for this growing public health problem.