04 Nov Challenges of Controlling Pain While Minimizing Risk of Opioid Use Disorder
MedicalResearch.com Interview with:
Jack E. Henningfield, PhD
Vice President, Research, Health Policy, and Abuse Liability
Adjunct Professor of Behavioral Biology
Department of Psychiatry and Behavioral Science
Johns Hopkins University School of Medicine
MedicalResearch.com: What is the background for this study?
Response: Pain and addiction are complex and often intertwined disorders. Most pain patients treated with opioids do not develop opioid use disorder (OUD), and most people with OUD did not develop it while taking appropriately prescribed opioids, but some do and this reinforces the need for thoughtful, individualized, treatment of pain patients and people with OUD. Presently many doctors are under pressure to simply reduce opioid prescribing to pain patients, leaving many who would benefit from opioids suffering needlessly. Many people with OUD, especially low income and minority people and rural populations, are without access to care or receive substandard care that may not even include recommended medications such as buprenorphine.
Thus, broad stroke approaches to reducing opioid prescribing have exacerbated the problem of undertreated pain. In fact, abuse of opioids and opioid overdose deaths continued to rise even as opioid prescribing has declined. During this same time, there were increasing reports of apparently needless suffering and increased suicides rates in chronic pain patients.
MedicalResearch.com: What are the main findings?
Response: This is exacerbating the 21st century opioid epidemic, as undertreated pain patients turn to illicit opioids to relieve their pain, and people who need and want treatment for their opioid use disorder cannot access or afford treatment. Former Surgeon General C. Everett Koop said it best, to paraphrase, for many people it is easy to get deadly addicting drugs and hard to get treatment; as a nation we must reverse that if we are to more effectively address the needs of people with pain and addiction in America. The main challenge addressed by this commentary is how to achieve Dr. Koop’s vision. We believe that will contribute to better pain management and reduced opioid abuse, addiction and overdose deaths.
MedicalResearch.com: What should readers take away from your report?
Response: Strong science-based approaches exist for both pain management and opioid use disorder treatment. Fundamentally, treatment of both pain and addiction often benefit from programs that include medication together with behavioral and other support services. Inadequate reimbursement and a lack of providers trained in diagnosis or individual tailoring of treatment contribute to the problem.
Simply stated, services are not likely to be provided if they are not paid for. As a result, many people with pain or opioid use disorder remain undertreated and at risk for turning to illicit opioids which may be more accessible and affordable than appropriate medical care. This hurts low income people and minority population especially hard. A dramatic example of economic forces exacerbating the situation is that African Americans with opioid use disorder are 35 times less likely to be prescribed the most widely used buprenorphine-based medicines for OUD. This is partly due to their lower likelihood of having health insurance or sufficient income to pay for it. That is wrong from a humanitarian perspective and it is not good public health policy.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: Policy makers should support reimbursement of programs to manage pain and opioid use disorder to help make evidence-based treatments more accessible, appealing, and affordable. That would be considered a good application of behavioral economics, or as former Surgeon General C. Everett Koop advocated, making it as easy to get treatment as to get illicit drugs, (see footnote).
More research is needed to better understand how to minimize the risk of opioid use disorder in pain patients who benefit from opioid pain relievers. We also need to move more rapidly to replace the most abusable opioids with abuse deterrent opioids that have come on the market in recent years but which are often not used because insurance companies and the Veterans Administration are reluctant to pay for them. Hope is also on the way in new generations of opioid and non-opioid based pain relievers that are lower in abuse potential than conventional opioids. Some of these have been fast-tracked by FDA and could be marketed within 1-2 years if approved.
Finally, we need to make it as easy to get treatment for OUD as it is to get opioids of abuse. That was called for by the 2917 White House Opioid Report but there was little increase in federal funding. In addition, we need to better address the needs of people with OUD and pain who do not find relief even when given reliable access to existing treatments.
MedicalResearch.com: Is there anything else you would like to add?
Response: Sound policies including reducing economic barriers to treatment for all people are vital. For people who continue to use opioids recreationally harm reduction interventions such as needle exchange programs and the distribution of naloxone will increase their likelihood of surviving until they are ready for treatment or treatment becomes an option. I believe that is humane and sound public health policy. Federal and payor policies around reimbursement of diagnosis and treatments are needed to support adequate management of pain and OUD. Evidence-based first line treatments should be available based on need and not income level, where the person lives, or their ethnicity. For people who find unconventional approaches to pain and opioid use disorder management more desirable and effective than approved treatments (e.g., dietary supplements and acupuncture), such approaches should also be supported and not discouraged because they are not FDA approved., 
Finally, stigma remains a problem that must be countered with science, understanding and compassion. We have long known that patients suffering from OUD are stigmatized, which results in their hiding their disease rather than seeking treatment. Many clinicians won’t treat them. This stigmatization is now being carried over to pain patients who are on opioids and are now characterized by many as “addicts” if they use opioids or that they are weak and denied treatment by people who do not understand their pain. These attitudes perpetuate the problems rather than address them with adequate care.
Citation: Henningfield JE, Ashworth JB, Gerlach KK, Simone B, Schnoll SH. The nexus of opioids, pain, and addiction: Challenges and solutions. Prev Med. 2019 Oct 18:105852. doi: 10.1016/j.ypmed.2019.105852. [Epub ahead of print]
Funding sources: The time and effort of the authors on this article was supported by PinneyAssociates without input from any commercial interests.
Declaration of competing interest: In the past three years, the authors have provided consulting services to pharmaceutical developers on the evaluation and regulation of medications regarding their potential for abuse and addiction including opioids for pain management and treatments for OUD and overdose. Through PinneyAssociates, the authors also provide consulting services on cannabinoids and dietary supplements, including kratom which is used by some people to manage their OUD. PinneyAssociates provides consulting services on tobacco harm reduction on an exclusive basis to Juul Labs, Inc. Within the past three years, PinneyAssociates has consulted for British American Tobacco and Reynolds American Inc and subsidiaries on tobacco harm reduction. JEH also owns an interest in intellectual property for a novel nicotine medication that has neither been developed nor commercialized. JBA and BS are employees of Harm Reduction Therapeutics, a nonprofit entity pursing the development and approval of over-the-counter naloxone for opioid overdose; and JEH and SHS provide support to Harm Reduction Therapeutics through PinneyAssociates.
 Koop, C. E. (2003). Drug addiction in America: challenges and opportunities. Mil Med, 168(5), viii-xvi.
Koop, C. E. (2006). Health and health care for the 21st century: for all the people. Am. J. Pub. Hlth., 96(12), 2090-2092.
 2019: Ashworth, J., Wang, D., Henningfield, J.E. Comment in response to: Request for Information for the Development of a CMS Action Plan to Prevent Opioid Addiction and Enhance Access to Medication-Assisted Treatment. Department of Health and Human Services (HHS) and The Centers for Medicare & Medicaid Services (CMS). Submitted via email to: PainandSUDTreatment@cms.hhs.gov
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