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Failure to treat chronic pain real issue behind prescription opioid epidemic

Person with shoulder pain

Among all the stories I've seen about the prescription opioid epidemic, only a few touch briefly and lightly on the major factor driving all the prescriptions -- chronic pain -- before they skip on to recommend better patient and physician education.

"For 20 years, doctors have prescribed opioids -- drugs such as oxycodone, hydromorphone, fentanyl and others -- liberally for chronic pain, one of the most common problems we see." wrote David Juurlink, head of the University of Toronto's pharmacology department, in a Globe and Mail op-ed piece.

"Chronic pain not caused by cancer is among the most prevalent and debilitating medical conditions," said a New England Journal of Medicine (NEJM) article, "but also among the most controversial and complex to manage."

"Chronic pain is a major public health problem," said an article from the U.S. National Institutes of Health, "which is associated with devastating consequences to patients and families, a high rate of health-care utilization, and huge society costs related to lost work productivity. The existing treatments for chronic pain are unable to address the problem and better therapies are urgently needed. The need for these therapies is the backdrop for the expanding use of opioid drugs."

Chronic pain is not a given, it's a catastrophe

Let's define chronic pain as constant, incessant, stabbing, aching, throbbing, agonizing sensations that people live with day in and day out, with no hope they'll ever get better. Between three and four out of every 10 Americans meet each day painfully. "More than 30 per cent of Americans have some form of acute or chronic pain," says the NEJM.  "Among older adults, the prevalence of chronic pain is more than 40 per cent."

Here, for me, is where most reports start to lose perspective. The NIHI article continues, "Given the prevalence of chronic pain and its often disabling effects, it is not surprising that opioid analgesics are now the most commonly prescribed class of medications in the United States."  I take issue with practically every clause in this sentence.

First of all, having 40 per cent of the population in chronic pain is not a given, it's a catastrophe. In Canada, the rate is half that -- one in five adults, or 20 per cent, according to the Canadian Pain Society. European data is similar.  

Second, prescribing opioids was not a natural or even logical result of these pain levels. A lot of medical people now regret that health care adopted a "fifth vital sign" policy during the 1990s, apparently as a result of military hospital concerns about veterans' pain being undertreated. Administrators required any nurse who checked a patient's four vital signs (pulse, temperature, heart rate and breathing rate), also to take "the fifth vital sign" and ask the patient to assess their pain. This well-intended practice almost inevitably led to more pain medication prescriptions. But that's not how opioid prescriptions became standard medical practice in the U.S.. 

Third, the American Journal of Public Health reports that one aggressive and deceitful company led the way in promoting opioids as safe for long-term use. Purdue Pharma introduced OxyContin during "a period of liberalization" in prescribing narcotics, with highly profitable but socially disastrous results. Purdue also pioneered marketing directly to doctors, with paid trips and personal pitches.

"When Purdue Pharma introduced OxyContin in 1996, it was aggressively marketed and highly promoted. Sales grew from $48 million in 1996 to almost $1.1 billion in 2000. The high availability of OxyContin correlated with increased abuse, diversion, and addiction, and by 2004 OxyContin had become a leading drug of abuse in the United States."

In a 2007 court settlement, Purdue agreed to pay the U.S. government a $160 million fine for fraudulently claiming that OxyContin was "abuse resistant," because it was a time-released medication.

Finally, let's get back to the chronic pain. In Canada, the main causes of chronic pain are shingles, surgery and fibromyaglia. In the U.S., causes include chronic respiratory issues, mental and substance abuse disorders and neurological disorders. Two of the main five causes are back pain and "musculoskeletal injuries" a term that usually includes conditions such as frozen shoulder, tendinitis, and yes, carpal tunnel syndrome.

The American Journal of Public Health article says chronic pain patients' numbers started to increase during the 1980s. Doctors started prescribing opioids in the 1990s.

"Productivity" boosts come at a cost

Lest we forget, the 1980s introduced the computer revolution. As a freelance writer, I bought my first computer in 1982, a KayPro64, in a buying co-op with a group of other writers. About the same time, newsrooms all around the world introduced computers according to the best technical advice. By 1992, hundreds and thousands of journalists were reporting intense arm or shoulder pain, or losing the use of their hands.

"Work-related injuries, long the plague of those who do heavy manual labor, have become a scourge among white-collar workers, too," Jane E. Brody reported in the New York Times in 1982. "Experts say hundreds of thousands of office workers are being disabled each year in an epidemic of motion-related damage to the hands and arms that is costing the nation many billions of dollars annually." 

The 80s also brought in deregulation, union-busting and constant pressure to increase  "productivity." "Productivity" in the business sense means increasing the value added by each employee's work. In theory, employers can do this by providing mechanical aids, such as offering carts instead of expecting workers to carry loads on their backs.

In the digital age, though, increasing  "productivity" usually means speeding up, adding more work or reducing wages and employment expenses.  Thus we have supermarket scanners and cashiers wearing wrist braces.

A cashier with a scanner is more "productive" because one job replaces two other jobs, the bagger and the inventory clerk.  However, the job's design is inherently injurious, starting with the constant wrist-flip to push products over the scanner. One study calculated that a cashier who also bagged products, lifted an average of 11,000 pounds a day over the counter to customers. If the cashier walks around the counter to hand you a bag, she's not being lazy -- she's probably nursing an aching elbow.  These days supermarkets are hiring baggers again and installing self-serve cash desks.

Although white-collar workers suffered computer injuries, by far the majority of those affected by RSIs were (and still are) blue-collar factory workers and pink-collar service workers. Affected workers suffer excruciating back pain, red hot elbow pain, frozen shoulders that howl at the slightest attempt to reach out, wrists that throb and hands that tingle and often simply stop working. One radio reporter filed a story about how, suddenly, on a major expressway, her right hand couldn't grip her steering wheel or steer her car. 

Workers' compensation costs skyrocketed in major urban states. In the U.S., statistics from the Occupational Safety and Health Administration (OSHA) and the Bureau of Labour Statistics (BLS) showed injury rates climbing and health costs soaring. Three per cent of lost time claims -- due to repetitive motion injuries -- cost 30 per cent of the compensation paid.

RSIs have proved difficult to treat, partly because they develop slowly, and mainly because -- after treatment for injuries  -- most injured workers go back to the same jobs. Fixing the patient usually involves fixing the workplace, and that's a very difficult project to sell in most workplaces if only one person is injured. Doctors have searched since the 1990s for cures, or at least pain relief. They were ready for a miracle cure.

This article is part one of a two-part series on chronic pain and the prescription opioid crisis. For part two, see Preventing chronic pain in the workplace would go a long way toward solving the opioid crisis.

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