Commentary: The Debate Over Opioids Should Be Much More Than It Is

Commentary: The Debate Over Opioids Should Be Much More Than It Is

By Ed Coghlan

The National Pain Report has been covering the debate over the use of opioids ever since the DEA rescheduled them.

It has become very obvious that the debate over the use of opioids to treat chronic pain has been hijacked—by the extremes on both sides.

The anti-opioid crowd—driven by government and addiction advocates—would have you believe that opioids are evil and lead to addiction, suicide and pretty much the end of the world as we know it. They have been loud and the major media of the country have been their echo chamber.

The pro-opioid crowd—driven by patients and patient advocacy groups—would have you believe that the concerns about abuse are overblown and that they are being denied access to the only thing that can help them. They are frustrated that more people aren’t hearing their side of their story.

Both sides are a little bit right and a little bit wrong.

Like most disagreements, it’s not an “either/or” argument.

There is enough room between the sides to drive a truck through.

That’s why this letter published in the New England Journal of Medicine caught our eye this past week. Dr. Daniel Alford of the Boston University School of Medicine did a great job of defining what the middle could look like in this very important argument.

For the anti-opioid crowd he says, “slow down”.

Groups lobbying against prescribing opioids for chronic pain remind us that the effectiveness of long-term opioid therapy has been inadequately studied. I believe that this is a case of absence of evidence rather than evidence of absence. As we await scientific evidence, questions remain regarding how best to address the epidemic of prescription-opioid misuse now. Groups advocating quick fixes believe that regulations that limit opioid availability are the best plan. This strategy is well intentioned and will certainly reduce opioid prescribing, but such blunt approaches will also limit access to opioids for patients who are benefiting or may potentially benefit from them.”

For the pro-opioid crowd he says “We hear you, but you need to listen too”

“Managing chronic pain is complex. Chronic pain is subjective and can present without objective evidence of tissue injury, which results in diagnostic uncertainties despite our most thorough assessments. Patients with chronic pain are desperately seeking immediate relief from their suffering; they tend to have unrealistic expectations regarding the potential benefits of opioids and not to fully appreciate the degree of risk conferred by escalating their own doses in a desperate (yet futile) attempt to obtain pain relief.”

The solution?

Common sense, better education of doctors, especially for the primary care physicians and their patients, about how to prescribe and use opioids responsibly.

“I believe that the medical profession is compassionate enough and bright enough to learn how to prescribe opioids, when they are indicated, in ways that maximize benefit and minimize harm. Though managing chronic pain is complicated and time consuming and carries risk, we owe it to our patients to ensure access to comprehensive pain management, including the medically appropriate use of opioids.”

Read the letter and let us know what you think.

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Authored by: Ed Coghlan

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Jean Price

Dr. Oberg…most people who know me think I’m the eternal optimist, and they’re mostly right, even where my personal life with pain is concerned. I always say if you don’t count bodies, I’m the most blessed woman in the world! Yet I have a built in sense of reality and consequence weighting that goes along with my optimism. And sadly, I agree with you! We’re thrown a stale crumb through someone’s statement and the advocacy groups seem to say “look, progress!”. I don’t see that at all. And unfortunately I think it will get worse before it gets better, too…if it ever does get better in this media fed, politically managed climate! Perhaps it’s time to look at ways to bolster our coping and our self worth and make a list of everything we’ve heard used that can give us a moments break from the pain, and share it with others. We need to set up a buddy system for those who are feeling at risk of giving up in the fullest measure, since there have been increases in suicides among pain patients alluded to. We are our own best health care, we’ve always been. Now may be the time to lean on this, because we won’t be getting much other help at all if the reigning powers have their way. And I think it’s time for our advocacy groups to wake up to this too! On the same day the CDC made their announcement, the Pain Foundation posted their “Terrific Tueday” spot on FB!! Surely they realize we weren’t feeling too terrific with the news of the CDCs success! Surely they know that was not compassionate and didn’t feel as if they had their hand on the pulse of our issue! Surely….
I’m so sorry your life has been derailed also, by what is supposed to be the most selfless, caring profession known. I guess the reality is pet groomers have it over many in this profession. And it’s a sad day in health care. And a very sad day to be a patient with pain. Keep valuing yourself, and I wish you comfort.

Richard Oberg M.D.

Jean – I’m sorry to say I don’t see any of this going anywhere. There’s a bitter truth to ‘it’s going to get worse before it gets better’ and re-reading this article and seeing more nonsense going after the FDA now about cinches it. I was considering submitting a post I’ve written about how totally absurd the approach to this has been and how we have 5 obvious ‘epidemics’ worse than prescription drugs but they win. Even a seismic shift in attitudes wouldn’t fix where we live…… ever. It was bad 20 years ago with few providers and poor access and those few physicians who would script for opioids long term even then were considered controversial in quiet whispers among physicians in our system and now won’t be replaced. I have no idea where people live that ever got what’s supposedly driving this ‘epidemic’ but it’s sure not here and the current BS has ended what was here. It’s amazing how callous the language of someone purported as reasonable can seem when you’ve had to give up getting effective care and your condition’s just worsening beyond tolerance as anyone with a medical degree is supposed to know (and some do know but now just shrug). My disease began when I just turned 39 (years before being correctly diagnosed) and it was no coincidence my first thoughts being a physician were ‘I’m screwed’. Even then patients with ‘invisible’ diseases were treated badly. Some conditions aren’t rocket science and I truly feel sorry for anyone with something more common. I’m far from the first person to say it but being an insider make it all the worse as I know you know. More online now about the all-too-accurate 6 minute patient visit everyone’s probably familiar with consisting of physicians and their tablets giving furtive glances while asking about any changes and filling in scripts and out you go – and most wouldn’t guess being a physician/patient makes it worse as your health summaries are more succinct. You might get a 20 sec stethoscope ‘exam’ so they get the full visit charge which has always been absurd if you walked into the room and have stable vital signs. It’s largely a useless ritual. Alford writes as if prescribing opioids for someone even with a disease anybody can look up and read is bad needing pain control is somehow too complicated to get even with a 20 year record of worsening disease and 100% compliance…… well, pretty much speaks for itself. There’s no superhero out there to save us – there’s nothing about appropriate pain control that’s ever been controversial other than it doesn’t fit the model of 21st century medicine and for many like Alford that’s too honest to say. Like the politics of today this is a ‘movement’ by individuals who’ve helped destroy my career and my life along with it. Physicians have more important things to do like whining about ‘the system’, their incomes, or non-existent lawsuits (unless they’re REALLY bad)… Read more »


Very true. I’ve seen so many articles claiming that “the long-term use of opiods is of questionable benefit.” So what happens after they yank our prescriptions? No one seems to know, but the assumption seems to be that the patients will be happily pain-free despite being denied relief.

I’m tired of being “collateral damage” in the War On Drugs.

Jean Price

Dr Alford’s statement that he believes the medical profession is compassionate and bright enough to prescribe opioids when needed begs the question of …even with interference from the government, the CDC, and the DEA? And even in the face of offices being invaded for record searches and possible unwarranted legal actions! He still uses the epidemic word…and although he did make some statements with some truth in them, I feel the pendulum is still tilted in direction of those who oppose any benefits from opioids. The brightness he alludes to is also in question when doctors aren’t taught enough about pain in general and are not well versed on medications versus invasive procedures which carry a great deal of risk. As for the compassion, that too is slipping from much of health care. Just look at Facebook to see Nurse sites offering jokes to post about “presumed pain” and druggie behavior! It’s a sad day for compassionate care when one of our senators is working to remove the only questions about pain treatment from the hospital patient satisfaction survey because “certain” patients who don’t deserve medication might influence these scorings…and therefore hospitals would receive less government reimbursement! So pain no longer counts! Unfortunately compassion takes concern for the patient…and belief of the patient…and this suffers in our current climate. Hopefully, voices like his will join in our cause for better pain control…but it’s going to be hard with so much verbal, powerful opposition.

April Dawn

yes! Thank you for being blunt and honest. I have been in chronic pain for over a decade now. And as I have decided not to end my life (although it is a battle sometimes), I fight every day just to get up. I fight to find ANY solution to reduce my pain. If my pain medications are take away, i won’t be alive long. They allow me to have a small window of time to reduce my pain to a point in which I can think clearly and spend time with a friend or go to an alternative treatment such as massage. Without them i would have been dead years ago – period. And there are so many more out there in the same situation as mine. people – doctors included – make so many assumptions about what it is like to be a person in chronic pain – and 90% of the time it is not just wrong but highly insulting and damaging to our treatment.

Fruit Loop

There needs to be MUCH more information out there about chronic pain than the internet. We need MORE documentaries and MORE newspaper and magazine articles. People don’t search the internet for information on chronic pain unless it affects them personally. The public gets a thorough education about breast cancer and heart disease but chronic pain is rarely heard from.

Pain doctors could use more training about pain in medical school. Docs themselves have a tremendous bias about patients with permanent pain. I wish I could give my body to the FDA and DEA for just one day, as well as the anti-opiate crowd. They don’t get it.

I’ve been living with chronic pain for almost five years, and I truly wish I had been killed instead of just injured. Everyone gives me the big,round puppy eyes and “oh, don’t say that!” and I want to slap them. I’ve lost my job, can’t participate in the sports I love, had to declare bankruptcy because of my medical bills, lost my car and I’m about to lose my house. You tell me what’s good about any of that.

My meds make the pain bearable enough to get out of bed, but that’s about it. My relatives, family members and (former) coworkers don’t believe it’s real. I’m sick of people putting their arms around my shoulders and telling me they know this is hard for me to hear, but my body is just making me think it’s hurting so I’ll feed it more drugs. They tell you about their aunt’s mother-in-law’s next door neighbor’s cousin’s best friend who tried a tofu diet and cured their pain…..

Even pain clinics display bias. I have to fill out questionnaires with questions such as “Does anyone else in your family have a problem with substance abuse” and “have you ever been raped?” and “have you ever been a victim of domestic violence?” None of those things is a pain patient’s fault, but the doctor punishes them if they answer yes. It should be illegal to base treatment on ANY of those circumstances or deny a particular course of treatment! They don’t ask a cancer patient those questions. One doc told me she knows exactly what chronic pain feels like – she treats it every day! That’s like saying she understands how it feels to be dead because she works in a funeral home.

More needs to be done for pain patients. Much more. Stop talking about it and start DOING it.

Melissa Redwine

The most dangerous drug there is, is legal. That would be alcohol, it has taken more lives then all the pain medication combined, in one way or another alcohol has taken the lives.

Richard Oberg M.D.

Thanks always for your efforts Ed. Many excellent comments here from Richard Lawhern (I recommend everyone read other things he’s written on-line), Dave, etc. I respectfully submit Ed that you have correctly defined the anti-opioid crowd but not the presumed other side – pro-opioid – similar to the guy who wrote the NEJM letter this post is based on. In logic there’s something very important called ‘false equivalence’ – that there are always two sides to every issue that both are equally valid which then leads to some particular solution which can only work if there truly is equivalence. This has never been the case with this issue and the ‘common’ in common sense is non-existent. Education sounds good but won’t fix this – physicians of all stripes deal with medical management much more complicated than this and for them it’s more a matter of choice. Even if it did do something there wouldn’t be any positive outcomes for at least a decade (the time for new physician training) so legions of us are just out of luck? I sure hope not. The anti-opioid side’s healthy, have the ear of media/government/DEA, are employed and empowered with misleading statistics about everything, and the presumed ‘other’ side – those of us posting here – have what exactly? Pain, disability, lock out to care, and what you’d expect from discrimination and minority status. I don’t see myself or others who’ve been denied care as equals about anything here. Patients can’t advocate for themselves when they’re being called addicts. The Zika virus in Brazil alone caused an increase in cases of fetal microcephaly from 147 in 2014 to 4000 in 2015 – quite a trajectory don’t you think? Much higher than the trajectory for opioid problems and, on Feb 8th 2016, CDC elevated their EOC (emergency operations center) to Level 1 – the highest – for Zika yet they don’t call it an epidemic even in Central/South America – if opioids are why not this? The WHO (World Health Organization) doesn’t either. The CDC told me the misleading statistics provided to the anti-opioid Consumer Reports issue were to show trajectory – why is that important in the opioid discussion but not for Zika??? I commented similarly to the ‘words matter’ post and respectfully submit that provocative language, misleading, and often bogus or distorted statistics are being used by the other side. Calling them out isn’t being partisan to anything and isn’t a ‘side’. As a pathologist and critical thinker I did this for a living and do this for everything. Anti-opioid proponents have essentially cried fire in a crowded theater leading to significant patient harm and are influencing public policy and should be stopped. The FDA is the only government agency that ‘gets it’ and was hammered over their appropriate approval of Zohydro (long acting hydrocodone) – look up the patent nonsense published by groups that opposed it said which were 100% WRONG and the few brave souls who called them out on it.… Read more »

mark Ibsen

I can echo Dr Webster.
It’s about the patient.
Patients are upset.
They feel betrayed.
Pain acts like a terrorist.
And it’s very effectively terrorizes everyone in this conversation

I’m thinking the queen could contribute hear “keep calm and treat pain”


I completely agree. We need to keep the focus on chronic pain and it’s treatment (or difficulty in obtaining treatment). And I am with you–seems we should be able to sue for our basic human rights and protections against harm. I think that is what it is going to take. Someone, somewhere will have the means to take this issue off the back page and put it on the front.

April Dawn

Although I agree with the fact that alcohol causes all kinds of damage, to both the person drinking and to others around them, I am curious as to how it fits here in this issue. Maybe I missed something, but it seems we are talking about the use of a medically indicated treatment – medication – needed to give a patient even a few hours of quality of life. As far as i know alcohol is not a medication, nor is it prescribed. This is the kind of confusing of issues that is part of the problem. We should be focusing on patients in pain and what is getting in the way of them receiving medication to relieve pain, not on people drinking irresponsibly or criminals and drug abuse. I hope this makes sense. I am in pain now and it does get in the way of thinking. But I just wish we could keep the topic and concern on diagnosed sick suffering people who are being denied clinically indicated pain medication. Medication – not evil drugs that they bought from a drug dealer. So much prejudice an shaming is going on, guilt placed on us when judgments should not be leveled upon us. We are not criminals. I know of no other illness symptoms (chronic pain) and no other medications that are treated this way. personally, I wish medical decisions could be kept between me and my doctor. Because I have been working with her for years – she actually knows my entire medical history, she knows me, an she knows how much my quality of life is improved by these medications. But she is constantly harassed and threatened about the prescriptions she writes. It is no longer about what is best for the patient – it is about possibly being punished, even losing her license, defending her medical decisions to people who have no idea about me and my life and then there is an entire new treat with pharmacists as well. They should have no right to question me about what illnesses I have or question my doctor of many years. What an insult to my doctor and myself. They should be focusing on getting the correct medications to the correct people in a timely manner and answering questions about side-effects or when/how to take the medications. I have been questioned like a criminal and shamed – as has my care-giver – when going to pick up pain medications from the pharmacist – this has NEVER happened with any other medication – this is a big problem. i wish i could take legal action. It causes me physical, medical harm. These are the kinds of things we need to focus on – the patient in horrible pain being forced to experience more pain and shaming and humiliation.

Kristine (Krissy)

Kim, it wouldn’t hurt to make a big stink about alcohol, but I don’t think it will do us much good. I like it when people are writing and they put in the statistics of abuse, death and family ruin because of it, however. Does anyone actually know if statistics other than death and DUI even exist?


So I want to know if we r going this far with regulations, why isn’t the misuse of alcohol (which is a drug) and the ramifications of its misuse being further examined?

April Dawn

It is extremely difficult to listen or have patience or do anything else when you hurt so badly, for so long, that you are barely surviving. Before anything else, the doctors and anyone else who is involved in decision making, needs to get past the blockage and denial and truly understand the reality of the chronic TORTURE we are experiencing. Every time a doctor refuses to prescribe to a patient with a chronic pain illness, they are contributing to this torture. Period. We are not criminals, we should not be put on trial. Actually we aren’t even put on trial – many doctors are just assuming we are guilty. Yes, it is complicated. Yes, we need a lot more than just medications to treat are illnesses, but we should not be tortured (and make no mistake that this is what it is – which drives people to suicide), while better ways are argued over and figured out and made into political battles to win races….


Hmm, just reading the comments I can see we are fractured. How can we, those with chronic pain, effect change in those who have never had to live with it, if we are trying to one-up each other (“my pain is worse than yours”), hyper-focusing on opioids only (“nothing else works”) and sending mixed messages (“I quit all my meds and have mind-over-matter, and my pain is worse than yours”).
Where can we come together on this? How can we say what is important? I think a common ground may be that we all want our doctor-patient relationship to be private and not be interfered with by the DEA. That we know our bodies and what works IN it (how do you know opioids won’t work for me?). That abusers should be held accountable for their own actions, not me (of course, this is not politically popular).
We need to make noise, but in unison, and with clear objectives. We have a lot of work, and a long way to go.


Opioids make many chronic pain patients functional and able to work, socialize, and do a lot of things they wouldn’t be able to do. There are side effects. Other treatments that help are not covered by insurance or have co-pays that add up over time. Patients must limit the times they are use them. Pain patients are not the reason drugs are abused. Drugs are abused because they are misused and available. Much education needs to be done in all arenas. One of the huge issues is pain is subjective…not objective. Hence not believable to many.

The article by Alford echoes the believes of many who have been treating people in pain for decades. I suspect it also echoes the believes on many with persistent pain. But I have to disagree with this editorial that there are two opposing groups, one anti-opioid and the other pro-opioid. There certainly is an anti-opioid attitude being promulgated throughout society but I rarely hear or read pro-opioid per se comments. Advocacy for people in pain to receive appropriate treatment is just that, appropriate treatment. Sometimes the only available treatment that works is an opioid. That doesn’t make one pro-opioid. This is being pro-patient. Most people on opioids for pain would prefer non opioid therapy if it worked and was affordable. It is very important to not make the discussion about opioids. It must always be about what is best for the patient and sometimes that could be an opioid and sometimes it means avoid opioids.


I have Chronic Regional Pain Disorder, or CRPS, from non-diagnosed osteoporosis and I suffered from 4 broken metatarsals and a broken ankle within 1 year, each time the cast temporarily came off, I broke another bone. My Orthopedic Doctor didn’t realize why I kept breaking bones, he tried walking casts, hard non-walking casts, a magnetic wrap to help with bone healing and finally gave up. I left crying, because by then, I was in excruciating pain, every injury just multiplied my misery. I found another Orthopedic Doctor that immediately recognized what was happening to me, but it was too late to treat the CRPS, as it developed during a long year in casts. The pain is excruciating, needles sticking into my skin, muscle contractions, sharp nails sticking DEEP into my foot and ankle, and the pain has traveled from my foot to my hip and now my right foot is starting to mimic the condition. I tried the spinal injection 3 times, but to no avail. My pain Doctor just threw up his hands and said he could do nothing else, go back to my internist. There is no cure. So, in order to have some “life”, I must rely on pain medication, just enough for me to function. I’m not a junkie, I have a full time job, I keep my home, although not as clean as it once was, but I have extreme fatigue from doing “normal” things that most take for granted. I tried physical therapy also, but the physical therapist was at a major loss of what to do, Hot packs/cold packs/massage/then the ultimate insult and pain, riding a stationary bicycle. I gave him 3 weeks, and it only worsened my pain. I cry some, but not much, it’s not a pity party, it’s just what God has given me. I have some quality to my life, I just have to slow down and quit doing what causes me to suffer too much, and I have to rest alot more. I don’t need counseling, I don’t need to have some Government Official tell me to get over it, live with it or threaten to take away anything that might help me or other people like me. Walk in our shoes for just a day, and you’d be begging for some relief. I didn’t ask for what happened to me, and most pain patients would welcome a normal life! I’m not “addicted” to my meds, I’m “addicted” to getting up every day and make the best I can of it. It is unimaginable that SOME so- Called Doctors would even consider letting their patients suffer. Buck it up and get over it, well, I hope and pray that they never have to endure what so many people in pain have to endure, every day, EVERY DAY, morning, day and night, every movement, waking up is the easiest thing we do, ENDURING is the hardest thing we do. Please take into consideration what is being addressed here, REAL… Read more »

Dee Green

I think that what you are saying is true! What I have been experiencing in social media could explain some of the discourse: As an advocate for my spouse, every time that I try to bring a “common sense” approach to chronic pain treatment & the addiction treatment possible approaches- I’m immediately attacked by Antiopioid groups & accused of having “brain damage” from opioid treatment, being paid by Big Pharma & in one case, accused of being the “reason” that one woman’s son committed suicide! She was essentially saying that physicians are the true drug dealers, not black market supply & that if all opioids were illegal her son would be “alive today”😔 While I feel truly sorry for family members that have lost family members to overdoses (suicide?/accidentally), this group is being promised by the Antiopioid lobby that prohibition of opioid for treatment of chronic pain will result in no one having access to medicines to overdose with (remember alcohol prohibition?) The families who have “tragically” lost a loved one are being given false promises of an “easy” cure for addiction & overdose deaths ( grieving families are seeking relief from guilt, anger& fear) latching on to anything to attempt to relieve them- blaming the chronic pain community for not supporting their efforts to remove opioids from chronic pain treatment (vilify & marginalize the pain community continues)
Until and unless cool heads prevail the current environment of social media attacks against chronic pain patients, family members and treating physicians will continue. The CDC is being used to further the agenda of that lobby & refuses to address the needs of the 100 million people in the US who suffer with chronic pain (that’s 1 in 3 US citizens 😔) Media is being used to push the addiction model only!
The medical and scientific communities need to come together (yes, pharmaceutical industry as well) and perform the studies necessary to implement productive policies-Not knee jerk reaction policies to satisfy the groups that just happen to be louder & definitely not in secret meetings with hidden contributors (always produces tainted results)
We have a fed agency that already “regulates” medication specifics, why do we need other fed agency to do the same thing? To many “hands in the pie is truly an understatement”
Thanks for bringing some common sense to the controversy 😊


The opioid debacle reflects a failure of our betters to make intelligent use of research and decisionmaking for the benefit of society. Despite 16000 RCT’s on opioids- which cost billions of dollars- controversy remains as to the effectivenss of opioids. So research and researchers have failed the American public when it comes to guiding care with regard to opioids. In fact we could say the research inflamed the debate. And since government does have a role in regard to funding research- they failed, too. The excuses are unconvincing. They say we cant do long term studies on opioids- nonsense. In addition- they can do studies showing the effects, physiologicaly of opioids on pain processing. They don’t wish to consider the failure to have reliable and credible research- so they failed the American public big-time.
Having said that, science, should not be the sole guide to opioid use. For one thing science is biased and very imperfect- it focuses on populations and not individuals-and there’s more to decisionmaking then evidence. Peoples preferences, values, beliefs, experiences need to being given value- for if we fail to do that then science becomes an infantilizing force.
Unfortunately Doctors and researchers are certaintists- they have trouble with doubts and remain unregenerate with regard to poor pain care- despite the fact they admit to the many problems in pain care. They must believe that poor pain care is the natural order of things- and that they have nothing to do with poor pain care- I guess it must have fell down from an asteroid or something. So,frankly, when I hear of our betters talk of their concern with opioids- it rings hollow to me- for I know our betters will not take responsibility for their own failings with regard to opioid use.


I’m not for regular use of Opiods, period- I’n asyrvivor of numerous fractures and sports injuries and currently, permanenly Disabled w Nerve damage from CIDP- I kinow Pain like most folks never have- Opiods are good in the Short-term, MUCH overused Long Term. Look, if you a5re Disabled and Morphine gets you baxck to full-time work and doesn’t KILL you- who’s to say? But what I see more of is Palliative Opiod Use so folks can be comfortable doing nothing? I just yell out and cure w Pain and do my best to minimize it Otherwise—Plus it doesn’t help the Nerve Pain thzt much- and my conditions are Chronic

Kristine (Krissy)

I like that Dr. Alford shows us the need for further education on the part of clinicians. I might have called it “intense” education. I have always believed that education can solve just about anything, given the recipients are receptive and willing to do tough homework. In this mess, while we are dueling — pro and con — advocation for and against opioid drugs use, we all know there isn’t a black and white solution. A happy medium will hopefully be determined by the proper and “intense” working together of the government and the medical industry. Pie in the sky? So far it is.

Doctors are seemingly not showing up to the party. Working together, if government has to be involved, for the greater good, is what we are really crying for. But what will this take? A long time?

I have personally and certainly been caught up in an extreme level of hysteria and I am not comfortable with that. You see, the patients, the writers, the thinkers, the media, all need education too, as we scramble and flail about trying to find something someone says that makes “perfect” sense. Who’s job is it to educate us but ourselves? But where it starts is with teachers and manuals.

I learn new things everyday while reading and reading and reading, and after these few short years, I feel like I’m beginning to see through part of the foggy bubble I’ve been living in. I’m trying to make an effort to calm down and listen to things that matter: the rush to solve the pain patients’ desires and needs, the cries of families who have lost members to overdose and the frustrations on both sides. In what way should these be separated and in what way should these be integrated?

We all know we need to come to some kind of understanding because we certainly aren’t solving anything in our present state of mind. Intellectually we all know what we want, but putting that into practice is largely impossible without all-encompassing support, organization, education and foundation. Remember the phrase, “it takes a village…?” This one takes a country and how we get a country together takes a few lifetimes, if it can happen at all.

I give kudos to the passionate fighters and sincere advocates working while in pain, unrested, foggy, brain-exhausted and side-effect ridden. With turmoil comes growth, and we just happen to be in the right place at the right time, or the wrong place at the right time, or… you know how many ways it can be said. Depending upon how one looks at the whole scenario, one can reap the growth or tamp the soil and leave the seeds underground.

As a patient advocate and webmaster for chronic face pain patients over a period of 20 years, I see the issues of opioid treatment for chronic pain through the lens of their experience. This is indeed a singularly complicated issue. To sort through it and arrive at a mostly fair and balanced understanding of opiate therapy, it seems to me that several insights will be required.

(1) Opioid and Opiate management of chronic neuropathic pain do not work for all patients in either short term or long term. There is at least some evidence that genetics plays a role in drug resistance for both opiates and anti-seizure meds, for some patients.

(2) It seems clear from patient experience that a serious emphasis must be placed on short term intervention to stop breakthrough pain during “flares” which may otherwise do lasting damage as the body system adjusts to the toxic byproducts and gene changes which occur when pain is sustained for long periods. Opioids have a constructive role to play in acute pain of neuropathic origin.

(3) In sustained chronic pain, physicians AND PATIENTS will indeed require mandatory training or education. The coding and billing systems of US insurance systems presently discourage investment of the time needed both for training and for management of chronic pain patients. Serious effort must also be focused on detection of physicians who abuse their prescription privilege by running “pill mills” and patients who doctor-shop to feed an addiction.

(4) If “multi-modal” and non-drug therapies are to be used, then their effectiveness must be reliably demonstrated. I’ve done a fair amount of reading on some of these therapies, notably Cognitive Behavior Therapy. And I do not find the literature published by advocates to be particularly credible or convincing, given that most studies don’t replicate when re-performed by independent investigators. Coercing patients into these modalities of pain management can be profoundly counter-productive.

(5) We must also realize that in some cases, denial or withdrawal of opiates will drive chronic pain patients into street drugs like Heroin. The notion that restriction of opoid prescriptions will somehow lead to fewer overdose deaths is very doubtful. That said, a much better job must be done in educating patients to the risks of these last-ditch measures to control their pain.