How to help patients with pain reduce their opioid use

Shelley Latin's odyssey of chronic pain and opioids began innocently enough in June 2011, when she woke up with a stomachache. It took a year for the cause to be properly diagnosed – a bacterial infection in its gut – and stopped with antibiotics, but by that time the pain had taken on a life of its own, which was no longer related to it. # 39; infection. "I could not drive, walk, or sit. I could only lie in bed on my back, "she recalls.

Over the next five years, Latin, a legal aid lawyer in Oregon, took doses of hydrocodone ever higher, prescribed by a doctor, to manage her misery. It was disastrous. She could not concentrate, she felt overwhelming fatigue and, inexplicably, she was saying, "I cried constantly." Worse, her whole abdomen became so hypersensitive that just wearing clothes was painful . This was probably due in part to a paradoxical side effect of analgesics known as opioid-induced hyperalgesia.

Last year, Latin had enough. She enrolled for a week in the comprehensive interdisciplinary pain program at Stanford University, where she worked with physicians to reorganize her medications, occupational therapists and physiotherapists, and psychologists for Now the Latin is out opioids and treats her pain with meditation, exercise, psychological counseling and medications for non-opioid nerve pain.

Unfortunately, few of the 10 million Americans taking long-term opioids for chronic pain have access to such a stellar program. Across the country, state and federal authorities and insurance companies have cracked down on opioid prescriptions as a result of a 345% increase in opioid-related deaths between 2001 and 2016. In some states, legislators have restricted what doctors can easily prescribe. As a result, many patients are forced to reduce their drug use without the support needed to do so safely and effectively. "If a person takes opioids at high doses for many years, it takes time and work to help them eliminate them. How a politician thinks that knowing the answer to this question in a single solution goes against me, "says Erin Krebs, opioid researcher at the Minneapolis Veterans Affairs Health System.

In fact, there is very little research on the best way to reduce opioids in patients with chronic pain. For example, although studies show that drugs such as buprenorphine can help addicts recover, their value is poorly understood in the context of chronic pain. Last year, Krebs and colleagues published an article on 67 studies of opioids for pain patients and found only three high-quality studies and 13 "correct" ones. dosages, most people do better in terms of pain and quality of life. What is difficult is that the best studies have focused on multidisciplinary care and very careful patient monitoring – labor-intensive methods that are not widely available in the United States and rarely covered by insurance.

One thing seems obvious from research and clinical experience: the reckless restriction is not the right answer to the reckless prescription. "Forced compressions can destabilize patients," says Stefan Kertesz, an addiction expert at the University of Alabama at the Birmingham School of Medicine. Concerned clinicians such as Kertesz report increasing anecdotal evidence of patient distress and even suicide.

The brightest rays of light from this dark image come from an explosion of new research. In May, a team led by Stanford Anti-Doping Psychologist Beth Darnall published the results of a pilot study of 68 patients with chronic pain. In four months, the 51 participants who completed the study reduced their opioid doses by almost half with no increase in pain. There were no fancy clinics, just an attentive community doctor and a self-help guide written by Darnall. A key element was the very slow reduction of the dose during the first month. "It allows patients to relax in the process and gain the confidence of their doctor and themselves that they can do it," Darnall said. She is currently recruiting 1,300 patients for a multicenter study of this method that will also evaluate the value of adding behavioral support such as cognitive-behavioral therapy.

Other major studies are also underway. One, led by Krebs, will compare a program led by a pharmacist to modify treatment regimens to a program in which a medical and mental health team helps patients reduce their opioid use as part of the definition of personal goals. Given the high level of fear that most patients feel about change, it's a safe bet that any successful program will take a long time to be patient and compassionate.