Drug and Substance Abuse

The war on drugs and the war on pain

Claire Pomeroy, M.D.

In recent days, lawmakers, including President Trump, have responded to the worsening opioid crisis in the U.S. with calls for a national state of emergency.  Tragically, skyrocketing numbers of deaths from narcotics abuse are causing heartbreak for families across the nation. 

Some suggest harkening back to a bygone “war on drugs” with prosecution of offenders and a focus on interventions to stop the flow of drugs into the United States; others advocate for diverting offenders from the prison system to treatment programs.  Increasing numbers of communities are distributing emergency vials of naloxone to reverse overdoses. 

As a physician and researcher, I believe that while efforts to curb the opioid crisis will require a multitude of legal, law enforcement, regulatory and educational efforts, an effective response will also require a fully engaged “war on pain.” Debilitating, chronic pain is a sad fact of life for millions of Americans.  During my career, I have seen too many patients desperate for relief from pain due to injuries, cancer, arthritis and other illnesses – some saying they would rather die than live with their pain. 

Patients suffering from severe pain should not become the collateral damage in our war on drugs.  I call on our country to support medical research that advances the search for better, more effective, non-addictive pain medicines and therapies.

In 1996, the American Pain Society introduced the notion that pain should be regarded as the “fifth vital sign.” Standardized guidelines for assessing patients’ perceived pain levels (self-reported on a scale of zero-to-ten) were adopted in 1998, and updated by the Federation of State Medical Boards in 2004. 

In tandem with the new appreciation for pain as a vital sign, came a new “miracle drug,” OxyContin, promoted as a safe, effective therapy that would be less habit-forming than other narcotics because of its time-release formula. The resulting shift in prescription practices as physicians adopted the new drug made opioid pain-medication more accessible to consumers.  Too often, doctors were prescribing large numbers of pills “just in case” after surgical and dental procedures.  Within three years, by 1999, the number of people self-reporting the abuse of OxyContin was 400,000.  By 2003, it had mushroomed to 2.8 million. 

Other drugs such as fentanyl, heroin and “designer drugs” are now claiming increasing numbers of lives.  Deaths from drug overdose have been rising consistently, from approximately 30,000 per year in 2005 to more than 50,000 per year in 2015.  A new study reveals that opioid deaths could be 24% greater than currently reported.

As instances of abuse and death escalate, doctors are curbing prescription of more common opioids. New CDC guidelines issued to physicians last year reiterated the dangers of over-prescribing and advised prescribing the lowest possible dose of morphine-like drugs for the shortest amount of time, with specific exceptions for patients receiving cancer treatment or end-of-life care.

While awareness of the importance of avoiding unnecessary pain medicine prescriptions is critical, clinicians must also avoid the “flip side of the coin” – i.e., the mistake of undertreating pain.  Inadequate pain control is real, especially among minorities and the poor.  Unfortunately, many providers underestimate the pain of black patients, perceiving them to be at a greater risk for substance abuse.  People of color, the poor or the less educated are less likely to be prescribed opioid pain medications as compared with more affluent patients.

But while such interventions are important and necessary, the current opioid state of emergency will continue to take lives if we do not build on the foundation of biomedical research to find new weaponry in the war on pain.  The NIH has advanced a number of public-private partnerships to develop a new generation of pain medications with a reduced risk of dependence.  Researchers are making progress in producing opioid variants that would not create tolerance to the drug.  In addition, several preclinical studies have explored using vaccines against prescription opioids.

While the calls to resurrect the “war on drugs” should be part of the conversation, I believe we will fall short unless we also find better ways to control our patients’ pain.  We must work toward improved access to treatment programs and continue to investigate links between social determinants that could make individuals more susceptible to addiction.  And perhaps most importantly, we must invest in already promising biomedical research that will usher in the next generation of non-addictive pain killers and new pain management techniques that can ultimately win the war on pain. 

Claire Pomeroy, M.D., M.B.A., is president of the Albert and Mary Lasker Foundation, dedicated to advancing medical research.