Pain Management and the Intersection of Pain and Opioid Use Disorder - Pain Management and the Opioid Epidemic - NCBI Bookshelf
▻https://www.ncbi.nlm.nih.gov/books/NBK458655
This chapter addresses the scope of the problem of pain in the United States and its association with opioids, and the effectiveness of pharmacologic (both opioid and nonopioid) and nonpharmacologic treatments that may, alone or in combination, help individuals manage pain. The first section summarizes the scope of the problem of pain, focusing in particular on chronic, or persistent, pain, the form most associated with problematic use of opioids. The chapter then presents a detailed discussion of the various pain treatment modalities, reviewing in turn opioid analgesics, nonopioid pharmacologic treatments, interventional pain therapies, and nonpharmacologic treatments. This section is particularly important in helping to contextualize the evidence of effectiveness and limitations for various treatments for pain, given the burden of pain, the risks associated with undertreatment, and the pervasiveness of opioid use and related dose-dependent risks. The next section examines differences in pain experiences and treatment effectiveness among subpopulations, and the final section briefly addresses the intersection between pain and opioid use disorder (OUD) (discussed in greater detail in Chapter 3). A main objective of this chapter is to situate opioids within the broader armamentarium of treatments available for management of pain and to identify potential opportunities for reduced reliance on these medications.
The very real problems of underdiagnosis and undertreatment of pain are valid concerns, but it would be a mistake to infer that greater utilization of opioids would ameliorate these problems. As discussed below, opioids have long been used for the effective management of acute pain (e.g., acute postsurgical and postprocedural pain), but available evidence does not support the long-term use of opioids for management of chronic noncancer pain. On the other hand, evidence indicates that patients taking opioids long-term are at increased risk of OUD and opioid overdose, as well as a number of other adverse outcomes (e.g., cardiovascular events, fractures) (Baldini et al., 2012; Chou et al., 2015; Krashin et al., 2016). Nevertheless, opioids often are used in the management of chronic noncancer pain. As discussed in Chapter 1, for many years physicians prescribed opioids for chronic noncancer pain, sometimes in very high doses, because of the incorrect belief that the risk for the development of substance use disorders and addiction was low (Krashin et al., 2016). Emphasis was appropriately placed on inadequate recognition and treatment of pain. However, these concerns often were not balanced by a similar emphasis on precautions to avoid adverse effects, such as the development of addiction (Kolodny et al., 2015), and the increase in opioid prescribing that began during the 1990s was associated with a parallel increase in opioid-related substance use disorders and opioid-related deaths (Dowell et al., 2016; Kolodny et al., 2015; SAMHSA, 2015). It is estimated that opioid pain relievers (excluding nonmethadone synthetics) directly accounted for more than 17,500 deaths in 2015, up from approximately 6,160 in 1999 (NCHS, 2016). Moreover, these figures do not account for deaths from related conditions (e.g., bloodborne infections associated with OUD; see Chapters 4 and 5 for further detail). There are indications that opioid prescribing is decreasing, but as recently as 2015, tens of millions of opioids were dispensed by U.S. outpatient retail pharmacies (see Figure 1-1 in Chapter 1). The United States consumes the vast majority of opioids worldwide (Hauser et al., 2016).
