There are big reasons that Americans consume far more of these addictive painkillers than people do elsewhere.
The epidemic of opioid abuse will surely go down in history as one of the greatest disasters ever caused by medical treatment. We are right to hold greedy pharmaceutical companies and unscrupulous doctors accountable, but they are not the only culprits. As physicians who specialize in pain management, we are keenly aware of how both trends in the medical community and a uniquely American understanding of pain and its treatment conspired to lay the groundwork for the opioid epidemic.
This tragedy has made clear that doctors and patients must reject myths about pain and its treatment. This is no small task. Many of these beliefs are as deeply ingrained as they are wrong. Still, we must be willing to rethink. Pain treatment that trades in false promises has exacted a terrible price from communities, families, and individuals.
We can start by recognizing and jettisoning four widespread myths about pain: that it isn’t in the head, that opioids are universal pain reducers, that we have we have a right to pain relief, and that pain can and should always be eliminated.
Myth No. 1
To say that pain is in the head is to risk outrage. That’s understandable, because the medical community has historically discounted or dismissed pain, particularly among women and oppressed communities, as “all in your head.”
Yet, strictly speaking, all pain is in the head. The signal that reaches the brain is not actually pain; it is a message carried along pain-specific nerves called nociceptors. But the signal does not become a conscious feeling of pain until it has been processed by the brain. The brain is capable of taking the same signal and deriving a range of pain, from none to a lot, according to signals of danger in current circumstance and past experience.
When somebody presents to a doctor with pain, the doctor will try to find something in the body that could be generating the pain signal and that could be treated. But quite often there isn’t anything treatable in the body, or it is treatable, but the treatment does not eliminate the pain altogether.
Because the brain processes the signal as pain, the brain remains the most amenable target for treatment. When the doctor says you need to focus your treatment on what is happening in your brain, that should not be taken as an evasion or an insult. Doctors need to make clear to patients that they are not saying that pain is not real, or there is no treatment. Quite the opposite: What is happening in the head is what pain is. It is real, and it is treatable with a wide range of medical and non-medical therapies. Yet opioids compromise and even block people’s ability to benefit from non-pharmacological approaches including exercise, meditation, and behavioral treatments.
Myth No. 2
Prior to the 1980s, physicians were loath to prescribe opioids for chronic pain conditions because that was widely recognized as too risky. That changed when the newly established field of pain medicine began to argue for more widespread use, and this position gained traction in the decades that followed. We thought we could reduce the burden of chronic pain by treating it with opioids. This was an experiment, but prescribing for chronic pain in the United States skyrocketed — which taught us much more about what happens to the brain on opioids and why chronic opioid use is a bad idea. We learned that the brain’s adaptations to chronic opioid use, whether for pain or not, reduce opioids’ effectiveness in providing pain relief, produce side effects that compromise the enjoyment of life, and vastly reduce the drugs’ safety. These adaptations also make it very hard to stop taking opioids.
So why has a cry gone up in the media protesting reductions in opioid prescriptions? Critics of this move claim that cutting back on opioid prescriptions will lead more people in chronic pain to resort to illicit opioids or even to take their own lives. This is a serious misunderstanding. A patient with chronic pain who has never been prescribed opioids is usually responsive to a wide range of non-opioid and behavioral treatments and is rarely suicidal. It is the chronic pain patient who has been prescribed opioids and become dependent who is miserable and indeed vulnerable. This is because opioid dependence can be a wretched state, and having opioids withdrawn becomes more than these patients can bear. Opioid-dependent patients are likely to do best with careful changes in dosage under medical supervision. They can then better incorporate non-opioid and non-pharmaceutical approaches for managing their pain.
Myth No. 3
That we have a right to pain relief can seem axiomatic, but this belief was not always a given.
The right to pain relief was first established in end-of-life cancer care. In the 1980s, palliative care champions argued for extending this right to patients with chronic pain who did not have cancer and were not dying. They were successful in convincing the medical establishment and the general public of this.
But what does a right to pain relief mean, if not a right to opioids? It could mean a right to be heard, believed, and reassured, all of which are certainly therapeutic. But if there is nothing that can be fixed in the conventional medical way, what else can the doctor do? There are medications that improve certain painful conditions by reducing inflammation or calming irritated nerves, but the pain reduction is only partial. Treating related conditions such as depression, anxiety, insomnia, and PTSD can help. But at the end of the day, the lure of opioids is always there because it is only opioids that provide immediate and noticeable pain relief, at least when they are started. This immediate relief is welcomed by the patient and the doctor, but, as we now know, it is short-lived and is too often followed by devastation. A right to pain relief assumes there is an easy and effective long-term medical solution to most chronic pain, which there is not. This is probably one of the most difficult truths for modern Americans to assimilate. Turning to opioids may seem to be the answer, but we have learned the hard way that it does not work. Let us not create yet another cohort of disappointed patients with a compromised life and a failed promise of pain relief.
Myth No. 4
In many cultures around the globe, pain is accepted as part of human fate. With acceptance comes a measure of tranquility and peace of mind. Americans are an exception in seeing pain as something that must always be eliminated. Despite suffering similar rates of chronic pain, Americans consume six to eight times more opioids per capita than other developed nations.
Certainly, uncontrolled pain gets in the way of our pursuit of happiness. But can we actually eradicate it, and if we could, would that really be a good thing? Pain is profoundly normal and deeply embedded in human functionality. It is not possible to take away the ability to feel pain without taking away the ability to feel emotions or to function fully in society. Humans need to be able to feel pain because without pain, there is no pleasure.
Even seemingly senseless chronic pain is part of the brain system that responds to danger, regulates stress, and recovers from trauma. Our mistake is to try and abolish pain itself (with opioids), rather than addressing the heightened sensitivity that underlies most chronic pain and is not helped by opioids. We would do well to look outside our borders to consider how other cultures orient to pain and to ask ourselves if our pursuit of a pain-free life is realistic or even desirable.
The profiteers of the opioid crisis should be held accountable for the tragedy they visited on our society. The rest of us should fearlessly question the beliefs and assumptions that aided them.
Dr. Jane Ballantyne is professor of anesthesiology and pain medicine at the University of Washington. Dr. Mark Sullivan is professor of psychiatry and behavioral sciences at the University of Washington. They are the co-authors of “The Right to Pain Relief and Other Deep Roots of the Opioid Epidemic.”