I was a bit annoyed by this article that appeared on The Age website and was retweeted widely. The title – Opioid addiction: Treatments get people off painkillers, but it is a hard road – suggests the story is about prescription opioid addiction.
The body of the piece then sets out the familiar narrative (to me at least) that current prescribing trends in Australia are not yet following the best available evidence for treatment of persistent pain. Too much opioid prescribing, too little investment in pain services which can provide a flexible, comprehensive response to the problem.
The patient described in the piece does not sound like he was addicted to opioids. He sounds far more typical of the majority of opioid users with persistent pain. He was taking the drugs rationally and as prescribed, in an attempt to improve his pain. He was experiencing cognitive and other side effects that are common at high doses.
When offered a better option, he weaned himself off the useless medication under supervision and now has less sedation and more skills to self-manage his pain.
I get really frustrated when stories like this are portrayed as a heroic battle against addiction. They are not. It is lazy or cynical journalism to say so. Ceasing opioids is an end in itself if one is treating an addiction. It is not necessarily an end in itself if you are treating persistent pain. Intelligent reporting would not confuse the two.
The real story is that the evidence has changed and pain clinicians no longer think there are manageable consequences to high-dose prescribing. We also recognise that there are a number of much more effective therapies to help people manage their pain. There are plenty of reasons people do better when they see a pain service that takes a comprehensive approach to the problem of chronic pain.
To start with, there are sometimes relatively little-known but treatable conditions such as soft-tissue pain in the neck and back of the hip. I see a few of these each week and they usually do very well once the problem is adequately recognised.
In addition to a clearer diagnosis, expert care can target medications more rationally based on the mechanism of the pain, rather than purely the diagnosis. Using antidepressant medications for diabetic peripheral neuropathy pain seems counter-intuitive but can be very effective.
Interventions such as nerve blocks and injections can be a useful circuit-breaker to enable better participation in an overall rehabilitation program. Occasionally they work so well no further treatment is needed, but no pain clinician worth their salt would contemplate using them as the whole treatment most of the time.