While the story of the American opioid epidemic has largely, and in many ways fairly, been cast as the consequences of greed run amuck with bad science and misleading advertising, there’s an important tidbit that has often been ignored. You see, there was, and still is, a need to relieve persistent pain for patients. Today’s prescription opioids evolved from treatments for those with terminal cancers, designed to make their final days a little easier so they can spend their remaining time in enough comfort to enjoy quality time with their families and put their affairs in order.
Before oxycontin hit the market, the only way to do that was an opiate drip, so when Purdue Pharmaceuticals came up with a way to slowly release opioids in pill form, it actually improved the lives of cancer patients by letting them sleep through the night without being hooked up to bags with needles as well as giving them enough relief to get through the day. If only Purdue limited its ambitions here, maybe the opioid epidemic would’ve never happened. But we all know what came next. The company decided to push very hard to get into treating chronic pain, and that’s where it all went off the rails.
You see, chronic pain isn’t something that we really know how to treat, only how to manage because not only does it have a myriad causes for which we lack long-term or permanent solutions, every patient feels pain differently, even if it’s caused by the same injury or illness as in their fellow sufferers. If that wasn’t already problematic, pain tolerance and sensitivity to opioids is also unique, which is why some people don’t need or take many painkillers and easily stop while others can’t stop popping pills once they start. Couple that with irreversible degenerative damage we can’t yet treat, and you have the perfect recipe for a medical disaster if you don’t pay attention.
Generally, we can put opioid users in three broad categories. The first is the original cohort of terminally ill patients for whom addiction is irrelevant and who need the pills to get their affairs in order and say their goodbyes. The second is a group of chronic pain sufferers whose injuries are very difficult to treat with current medical technology, or who are suffering from long-term wear and tear we simply don’t know how to fix. They definitely need something to get through the day without pain and opioids were the easiest and cheapest way to accomplish that. The final category is people who had temporary pain from a nasty accident, surgery, or both, were prescribed far too many pills at way too high a dose for their systems, and got hooked.
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Considering that opioids fill a legitimate medical need, Attorney General Jeff Sessions’ idea that people should just say no to them seems particularly tone deaf and ignorant of the science involved. It’s one thing to use this simplistic 1980s catchphrase when talking about recreational drugs, but opioids are an important tool millions of people rely on daily. This is why the government’s position on combating their addictive side effects should not be instructing patients in pain to forgo their treatment, so the veterans of the War on Drugs don’t have to think too hard or come up with a different approach to dealing with controlled substances.
If we want to deal with opioid addiction, we have to treat each broad group very differently. This crisis was caused by pretending we had a magic fix for everyone affected by a persistent problem and it won’t be solved by repeating that mistake. There’s not much we can do for terminally ill patients except to create treatments to prevent them getting to a terminal stage and quality of life in one’s final days are very important, not just for the patients but for the friends and family who take care of them.
For people with injuries and pain we know will be temporary, the “start low, go slow” plan would help prevent flooding their system with far more opiates than they’ll need, setting them up for very unpleasant withdrawal symptoms after their prescriptions run out. Likewise, we now know that patients in need of short-term pain relief can do just fine with slightly higher doses of over the counter medications. This means we can revise the standard of care for them and withhold opiates without causing undue distress in a reversal of the badly misrepresented experiment on patients recovering from surgery which started the opioid prescription craze in the first place.
But the middle group, patients who have legitimate chronic issues with few, if any, effective treatments, are far more problematic. We can’t deny them pain management tools but also can’t enable their slide into addiction. Meditation, physical therapy, and special nutrition that could help them are often out of reach, especially in rural areas. And in cities, these amenities could be within reach physically but not financially, when insurance companies refuse to cover them. We need to invest in new pain relief methods and long-term solutions to degenerative injuries from working on one’s feet or with one’s hands for years on end, or trauma that never really healed.
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One of the simplest solutions would be steering these patients towards over the counter medications, as some doctors are starting to do. However, there’s a snag with that idea. They might not be strong enough to work effectively for many patients, and although we often tend to think of OTC pills as harmless, they can damage patients’ livers and kidneys if taken in high doses over a very long period of time. (Incidentally, excessive, long-term opioid use also tends to damage the liver.) OTC medication is generally meant for short-term uses, not as treatments for chronic conditions. They could do in a pinch for post-op treatments or minor injuries which shouldn’t require opiates, but they’re not going to be suitable for many patients.
Another approach is opiates that don’t create feelings of relaxed euphoria, so many addicts find irresistible. Since these drugs are still in development, we can’t say much about them, though we can assume they too would pose risks to patients’ livers as any medication of this type would. Of course, they could be safer and every bit as effective without the addictive traits, making them at least somewhat harder to abuse for determined addicts. But until they’re fully tested and approved, there’s simply not enough data to draw any conclusions about their efficacy in combatting opioid addiction.
Ultimately, a long-term fix can only come through treating degenerative and hard to heal bone and tissue damage with stem cells. Right now, the results are definitely mixed as some stem cell therapies appear to do nothing at all, others are almost magically effective, and yet others cause cancerous tumors and tissue rejection as their genetic makeup goes haywire. Mostly, this has to do with the immune response of the body to what it sees as a foreign invader and the regulation of the stem cells’ genes responsible for making sure they develop into tissues like the ones surrounding them.
There’s still a lot of basic science to be done in those areas to make sure the treatments will be able to work consistently for nearly all the patients who’ll need them. If we can work out how to keep the implanted cells growing and developing as intended, we can treat the tissue and nerve damage responsible for the chronic pain millions of Americans have to deal with on a daily basis with injections instead of addictive pills. If the government wanted to be part of the solution, it would incentivize pharmaceutical companies and research labs to come up with effective stem cell treatments.
We could try extending the shelf life of the patents that would be granted to researchers, or offer to pick up the tab for some of the more intensive trials and arrange for priority reviews of the submitted test results and safety data. The process can’t be too quick and take shortcuts, however. These treatments will be extremely powerful and demand caution and respect. But if we do things right, we can safely re-relegate opioids to being part of palliative care while still helping those in need of long-term pain management.
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