Opinion:  Pain and Opioid Use Among Seniors – Issues and Emerging Trends

Opinion: Pain and Opioid Use Among Seniors – Issues and Emerging Trends

By Sean Mackey, M.D., Ph.D.

Editor’s Note: Sean Mackey, M.D., Ph.D., is Chief of the Division of Pain Medicine at Stanford University.

Sean Mackey MD PHD

Sean Mackey, MD, PHD

Our country has both challenges with chronic pain as well as opioid misuse, abuse, diversion and overdose deaths. Recognize we use opioids to treat pain, how do we address this conundrum? This was the topic of a Senate Special Committee on Aging on February 24th, 2016. I was honored to testify on behalf of the Institute of Medicine and was asked to represent the work we did on the IOM Reliving Pain in America Committee. This effort was led by Chairman Senator Susan Collins (R-ME), Ranking Member Richard Donnelly (D-IN; sitting in for Senator Claire McCaskill (D-MO) who was just diagnosed with breast cancer), and joined by Senators Warren, Casey, Kaine, and Blumenthal. The full hearing can be found here.

I was prepared for this testimony and for the Q&A session to be highly charged and potentially confrontational. After all, the media present on an almost daily basis both young and old dying from opioid related deaths. Just the night before, Frontline presented a powerful contemporary look into the increasing heroin problem our country is facing. It is understandable to want to be angry, to react, to point fingers, and to dramatically restrict the use of opioids – all with the laudable goal of reducing opioid related negative consequences.

I share that goal.

I am also highly motivated to care for people suffering in pain. As a Pain Medicine physician, I know that for chronic pain, opioids are rarely a first line agent. However, I see patients all the time that are taking their opioids responsibly and seeing a persistent increase in quality of life and decrease in pain. Patients like Leslie, age 73, whom I saw the day before flying to Washington D.C.  Leslie has bad nerve pain in her legs and takes a small amount of opioid in the AM to help her function. She takes a second small amount in the evening that helps to reduce her pain so she can sleep. She has tried many other treatments (pharmacologic and otherwise) and finds that this approach has worked for her for many years. She displays no risky behaviors around her opioids. Her message to me was: “Don’t let them take away our medications without giving us something in return.”

I went to D.C. with that message in mind. And to be clear to the readers – I am neither “pro-opioid” nor “anti-opioid. I am “pro-patient”. And I receive no money from pharmaceutical industries.

My goal was to present our findings from the Institute of Medicine Relieving Pain in America report and the NIH/Health and Human Services National Pain Strategy (NPS). Both can be downloaded for free.

As mentioned, I was prepared for a contentious and emotionally charged testimony. It was anything but. I was pleasantly surprised by the leadership of Senator Collins and all the Senators for their knowledge, preparedness, and lack of posturing and clear desire to understand the situation. They asked good questions; and they listened to the answers. Most importantly, they came off as being willing to consider both sides of this tremendously complicated set of problems: Problems that will not be solved with a simple single solution or two but instead will require a comprehensive public health approach. I was joined by the following witnesses:

  1. Sean Cavanaugh, Deputy Administrator and Director of the Center for Medicare, Centers for Medicare & Medicaid Services, Washington, D.C.
  2. Ann Maxwell, Assistant Inspector General, Office of Evaluation and Inspections, Office of Inspector General, U.S. Department of Health and Human Services, Washington, D.C.
  3. Steven Diaz, MD, Chief Medical Officer and Emergency Medicine Physician, Maine General, Augusta, ME
  4. Jerome Adams, MD, MPH, Health Commissioner, Indiana State Department of Health, Indiana

All made compelling opening comments and responded superbly to the questions. Each, of course, is looking at the problems through his or her own “lens” and represents a view of the challenges and solutions. It is clear that it will take such a multi-disciplinary approach if we are to solve these problems. From my perspective, I am of the strong belief that release and implementation of the National Pain Strategy will be a critical part of the solution to both problems.

While there were many aspects of the hearing that I found compelling, there was one that particularly stood out. That was the discussion about the unintended consequences of patient satisfaction surveys on motivating physician behavior to prescribe more opioids to keep their patients happy. Senator Collins (with several other Senators) recently wrote a letter to Secretary Burwell outlining this concern. This is a very real issue and one that needs to be addressed. I had the opportunity to discuss this with Senator Collins afterwards and the fact that the problem extends well beyond the hospital environment and is of major concern in our outpatient settings. She seemed both interested and engaged. Bottom line, we need to make sure that we are:

1) Optimizing the patient experience.

2) Using the right tools/surveys to do so

3) Not inadvertently motivated other behaviors that would be bad for the patients.

In closing, I need to thank Jim Jensen from the IOM and his staff who were wonderful in helping with the meeting. And a special shout out to the Mayday fund and Carol Schadelbauer and Alisa O’Brien from Burness for their wonderful assistance.

This is both a challenging and exciting time.

It is challenging because of the very real problems with both pain and the opioid epidemic.

It is exciting because there are available solutions (e.g. National Pain Strategy) that can provide cultural transformation we need in how this country cares for those in pain – and help address this very real opioid problem. Overall, an incredible experience and one that I am hopeful will make an impact.

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Authored by: Sean Mackey, MD, PhD

There are 15 comments for this article
  1. Doug at 1:23 pm

    Janet, I feel your pain and totally agree with you that while attempting to slow or stop addiction. The federal government has only succeeded in, 1,) Arresting good doctors who only wanted to help their patients. 2.) Increasing the income of Drug Dealers and Cartels because people in pain simply NEED relief and if they can’t get it from a licensed professional, people in deliberating pain will try almost anything. 3.) Cause a Nation wide discrimination against people who suffer from chronic pain, and. 4.) Created a perfect way to thin the population.

    Driving honest and good people to the streets for pain relief has only succeeded in raising the numbers of overdose deaths. This is happening because, patients who were once under the guidance and supervision of licensed medical professionals using FDA approved medications are now taking unknown amounts of heroin and Fentanyl opiates to treat their pain. Then those who cannot find any relief are committing suicide. So we have to ask ourselves this.
    Are we going to continue to let this government sponsored PURGE continue, or are we going to stand up for our rights to pain relief and make a difference?
    I have read so many comments and postings where the person writing asks,”can you please help me?” Then fact is, the only help at this point we are going to receive is from ourselves. We have to advocate for the entire pain community, and everyone who can needs to join in.

    Yesterday I spent my entire day with a group of 29 disabled veterans. First, we talked about what has been going on with opiates and other prescription medications and the governments involvement.
    Next, we spent the rest of the day writing emails and letters to the senators responsible for the new opioid Tax.
    These guys knew nothing about pain groups on Facebook and other social media, the National Pain Report and the US Pain Foundation, or any of the other advocates for chronic pain because they couldn’t use computers and if anyone of them had a cell phone, it was an antique. So I showed them what I could and I had fun doing it.
    My point is, we can’t just sit around waiting for lighting to strike and public opinion to magically change. We must inform and help those who are unable to help themselves. Then we have to start making a lot more noise. It’s up to all of us and more.

  2. Janet Vierra at 1:51 am

    I have fibromyalgia, stenosis, scoliosis, degenerative disc and joint disease, protruding disks in my neck and back and then some. I have been taking opiates and they work for my pain. I follow the instructions on the bottle. I care about the drug addicts out there shooting up heroin, but why can’t people in severe pain get relief? If they don’t, suicide is usually the answer. I will do it too if my pain is not relieved. I have tried gabapentin and another one I don’t remember. I was on soma, but the DEA said after 7 weeks, it is just an addiction as it is ineffective for spasms. Tell the government to stay out of mine and my doctor’s business and worry about paying off their 16 trillion dollar debt.I have too many friends that have ended their life because of pain.

  3. Tim at 7:01 am

    I think BL said it right in another post. Most Chronic Pain patients are still getting and will continue to receive their opioids. I tend to agree because it has not been brought up with me at my pain management visits.
    There was a time when I was prescribed a higher dose and quantity. Surgery allowed me to reduce my medication. With that being said, I now have an extruded L4-L5 disc above a year old ALIF 360. I just completed 33 visits of PT and have changed the way I get in and out of bed, improved my posture and leg strength.
    All of these attempts to improve my situation are reported to my pain management folks along with images and documentation. Once the subjectivity of pain reduced by these means your prescriptions are safe and they may even be increased.

  4. Terri at 7:27 pm

    I have an aggressive form of Ehlers Danlos Syndrome which affects all the cartilage in my body. My spine is in horrible shape and no surgery can be done to help. I have chronic trigeminal neuralgia in 5 branches of my left face. I can’t even eat unless I take a pain medication. I take them to live and stay as functional as possible. Now the DEA, FDA, and CDC want everyone to be off pain medication. It is so discouraging to have come this far and still fight for my rights and the rights of all people who need medication.

  5. TIm Mason at 7:37 am

    Dave,
    Can you supply a link for information to the books that you have authored? I would be interested in reading them.
    Kind Regards

  6. Tracey at 2:07 pm

    I’m just going to say it – Any substance that can be used (consumed) can also be misused and abused. A government can restrict and/or ban to its heart’s content, but, as history has shown us time after time, that does nothing to shrink the addiction rate. Why? Because addiction is a primary mental health disease that can be caused by both genetic and environmental factors. A pill, a drink, a can of air, a plant does not “cause” addiction. The abused substance is just the symptom of something much larger and more complex.

    I’m a 42 year old adult who does not need the government to *protect* me. Currently, there is a large community of humans who are suffering to the point where suicide feels like the only available option to end that suffering. That is the epidemic. Think about it – our government is restricting access to much-needed medication to humans who are suffering based on the notion that a *pill* will instantly turn one into an addict. It’s absurd and outrageous.

    I’m just curious why it is “acceptable” (by our government) to treat recovering addicts with prescription opioid medication (a class of medications specifically approved for pain control) yet “unacceptable” to treat those with actual ongoing, 24/7/365 physical pain with that same class of prescription medications (again, a class that is specifically approved to lessen physical pain). It is blatant hypocrisy on our government’s part.

    (For the record, I have no problem with recovering addicts using short-term or long-term opioid medication approved for addiction treatment. My problem is the hypocrisy of our government. I would never wish addiction upon another human because I know that addict is also suffering in their own way, just as I would never wish chronic pain upon another human.)

  7. Augur at 12:48 am

    Doctors are violating the human rights of patients by withholding pain medications.

    When done to 116 million people, it constitutes a Crime Against Humanity

    The World Health Organization “Access to Pain Treatment is a Human Right”
    http://apps.who.int/medicinedocs/en/d/Js18774en/

    The Declaration of Montreal concurs: Declaration that Access to Pain Management Is a Fundamental Human Right
    https://www.iasp-pain.org/Advocacy/Content.aspx?ItemNumber=1821

    This needs to go to the International Criminal Court for prosecution, as doctors in the US are deliberately keeping 116 million people in untreated or undertreated pain as a modern day “Pain Compliance” methodology to generate extraordinary profits for their new “pain management industry”.

    This use of our pain against us is immoral, unethical manipulation of our lives, and must be stopped.

  8. Dave at 6:57 pm

    Dr Oberg- Of couse our institutions and our government has no faith in the capacity of the average Joe or Jane to make a decision that is best for them. And so they wish to coerce and compel the great unwashed to do what they think is best.
    I dont see too much probing or self searching or full and fair consideration of alternatives by our betters. So if they are better then the great unwashed- its a distinction without much of a difference. The betters seem rather stuck on a narrow range of ideas and solutions-they lack the fluidity and flexibility of being to meet todays challenges. And dont they always hold themselves as perfectly blameless with regard to current problems in pain care.
    But by calling for hard nosed rules and regulations and getting experts to say its for the public good-this only diminishes the publics capacity to grow and eveolve beyond the narrow rules of the betters(or should i call them Selenites or Vions).

  9. Kerry at 6:30 pm

    At this point talk is cheap. Our government in Washington is fantastic at having committees on having committees. They have absolutely no idea the unbelievable suffering they are causing a whole sector of our population that is not only forgotten but being forced to live in agony so another segment won’t get their hands on it! Has it even occurred to everybody that they are having not one bit of problem getting their hands on heroin and to the ER Drs and “pain specialists” that the patients begging for adequate pain treatment aren’t drug seekers? No! They are so sure they know what’s best for us poor misguided pain patients. We’re not stupid! Our bodies are in distress and the damage from no relief is much much worse for us in many ways. We are traumatized from sun up to sun up. It’s nice you were impressed with their attitudes but I promise you it’s totally inconsistent with the nightmare we are living everyday and from the sounds of this love fest hope is nowhere in sight!

  10. Donna at 1:39 pm

    I went to the link for the National Pain Strategy. There are recommendations for use of opiate pain medications. Not one was for chronic pain. Short-term, post-surgical and when dying from a fatal illness were given as the only instances when opiates should be used. And we, chronic pain patients, are not even mentioned.

  11. Richard Oberg M.D. at 12:02 pm

    I’m heartened to finally have someone like this on our side. Will be really curious to see if/how he changes the dialog. It’s also encouraging he labels himself a ‘pain medicine physician’ which is something real for a change. We have an epidemic of ‘experts’ right now who are anything but.

    Cultural transformations at a time when the Cleveland Clinic, Mayo Clinic, Vanderbilt Hospital in Tennessee, and other medical facilities considered ‘premier’ all have ceased scripting for opioids and won’t start back anytime soon (like in my lifetime). Worse, they’re peddling the delusion they don’t work. Melding patient medication into the drug addict/addiction thing did incalculable damage and listening to governors on this isn’t encouraging. How long did it take for us to go from ‘marijuana is the gateway to harder drugs says experts’ to what’s happening now? Does anyone really believe there’s not a group of zealots just waiting to topple that experiment also? The CDC/DEA rot is now being foist upon the FDA which was probably inevitable.

    Until we get physician patient advocates like myself, my wife, and others on board with a voice (to create a ‘side’ to this) I fear this refers to policy decisions without substance in many of our lifetimes of pain.

  12. Kathy at 9:50 am

    No one seems to be concerned about the Seniors who lacked basic Health care, which led to these long term pain issues. No one seems to have any concern about Poly pharmacy, which leads to a lot of Senior Deaths. There are a lot of drugs that effect Seniors differently. my Mother developed Lewy Body Dementia, and in her case she reacted badly or differently to many medications including Opiates. I know a lot of frail seniors, who were denied any kind of pain medication, while given Psychiatric medications to deal with their distress at being in pain. This Poly Pharmacy is a problem, but we don’t hear about that. We should be asking “What are we not hearing?” We are not hearing much in the Media about anything that conflicts with the “Opiod Epidemic Narrative”.

    It has been pretty disturbing to watch what happens to low income seniors when they interact with the Medical Industry. A lot my friends and acquaintances are now in that category. Because pain is such a contentious issue, the failure to diagnose or treat something that causes pain is leading to more Poly Pharmacy. The Poly Pharmacy leads to falls, and in many cases death, unrelated to Opiates. No one is collecting Data on this, or the number of elderly who have a Pain Condition that is either ignored or treated with other medications. I accompanied a 65 year old to his Doctor, he has Diabetes and hearing loss, and a little denial. No real Pain issues other than some arthritis, which he treats with an occasional NSAID. The list of Medications they gave him was confounding, some interfered with blood sugar, Statins, an Anti depressant, it was a list that would have interfered with hsi life. It was frightening. Another friend suffered a stroke, and has chronic pain due to the Stroke. Instead of prescribing Opiates, he is on a list of other medications, none of which are effective for pain, yet would be dangerous if he complied with taking them.
    There is a serious problem with the For Profit medical System. We don’t hear what happens to the millions of people who were denied medical care. The ones who did not die right away. We never hear about the millions who were either misdiagnosed or had the diagnosis postponed due to numerous referrals, or the Insurers who decided a course of action was a conflict with their profits.

    http://www.vox.com/2016/2/11/10966580/america-health-care-rations

    Here is an article about the expensive medications that are not covered, and how people are left in a holding pattern. There is no mention of Pain in this Article. This is just one Healthcare issue with no debate. People who are denied these basic treatments are often left with chronic pain. So it appears that there is an epidemic, yet he pain care is instead of treating the underlying condition.
    I am on Medicare, it took 2 Years of referral to see one of the few Neurologists left seeing Medicare/Medicaid patients. I had to get my MRI’s done over again for the Neurosurgeon. The Neurosurgeon finally told me i wasn’t bad enough yet for another surgery. It took 5 Years of referrals for the first surgery. During that time I had to leave my job because it was too distracting to work at a computer with the pain, and immobility in my arm and fingers. The Surgeon referred me back to “Pain Management” . I have done everything else over the last 20 Years PT, Nerve Ablation, Steroids, Chiropractors, Yoga, Pilates, even some non traditional stuff, Pitcher Plant Injections. Yet because I don’t have “Good” Insurance wo;t get surgery. It is too late for me, I had a Discectomy in 2001, after trying every Modality to avoid pain meds and surgery. I had a ruptured disc, after years of being told it was “All in my head, the disc ruptured because it was ignored, it was probably just a bulging disc when I first sought a Medical Diagnosis. I was Physically fit, ate well, went to countless Chiropractors.
    Watching my friends and acquaintances die in pain, or end up in Nursing Homes has been both horrifying and Educational. In many of these instances a simple, common sense approach would have either saved their lives or avoided hospitalization and Death in a Nursing Home. One thing I learned from Years of accompanying my Mother to the Doctors and Clinics is that there is no incentive to either correctly diagnose these conditions or treat them. My mother fell and broke her hip, which led to 2 Years of Nursing home hospitalization. She had 2 Painful Hip surgeries after the Dementia had gotten bad. She died in agony, like so many others, only some of them are even getting end of life pain meds. She had never taken a “Pill in her life”.

  13. DM at 4:16 am

    I don’t believe that chronic pain sufferers think that the opiate epidemic is unreal. I believe that all of us are just independently thinking about our own personal use for opiates. Many of us are mad because our pain medication has been either reduced to insufficient levels already or some have lost them all together. Hint, patients who don’t ask for more opiates then they already recieve, (unless the physician is testing for a suitable dose), they are not addicted. Medical professionals know the signs of an addict, but so many of them are operating in fear so they are gun shy of prescribing opiates all together. Cash patients are red flags as well.
    Physicians have to be allowed to practice their profession without fear of a law enforcement agency coming in and closing them down. Plus there are way more crooked cops out there then there are medical doctors. Law enforcement wouldn’t like it if physicians started going into police stations and arresting cops would they?
    Next, if a couple of college students could setup Facebook in a few nights, why can’t the government come up with a medical database that shares information between facilities about medical problems and prescriptions? 2nd hint, addicts doctor shop, not legitimate patients. Next the negative propaganda about opiates are directed to all people who use them and the pain community is feeling very discriminated against. The federal government should put commercials out stating that opiate medications are beneficial to chronic pain sufferers but should only be used as directed by a physician. The public needs to be educated that not all opioid use is addictive and there are those of us who really need these medications until someone can come up with a non addictive replacement.

  14. Betsy Green at 4:02 am

    I’d like to thank you for your articulate comments. Unfortunately I come from Vermont, which has received a very bad reputation for opioid and heroin use. While our problems are severe right now, they merely are in the limelight and behind or last in the nation’s curve dur to poor choices for blocking agents early on. But back to point, I suffer from severe CRPS due to being a survivor of domestic violence, and have had 3 nerve surgeries, and examined every possible holistic, traditional, and non traditional alternative for almeriorating my symptoms. Nothing has worked. Thankfully my doctor and I have a fantastic working relationship, whereby I have actually requested random urine testing, requested minimal dosage output from my pharmacy, as I have a 14 year old at home, and we do everything possible to be responsible about the drug. With that said, I have to admit, that while I could go off it immediately with no side effects physically ( such as an addict would have) it would change my quality of life. (No ability whatsoever to use my right arm without tears forming in my eyes).

    So I thank the pain community for keeping their eyes and thoughts open, to the fact that there are responsible patients and Doctors out there. I wish those stories were focused upon, and not the negative press. Thank you.

  15. Marty at 3:27 am

    It worry’s me about seniors not being able to get there opioids . My case is like many other seniors. I worked until I was 60 with multiple illnesses or pain and would still be working if not for a hysterectomy and hip replacement all within 6 months of each other and left me in so much pain that I can’t even use a cane anymore. I have to use a walker and at my age I hate it. I have so much life left in me but my back says other wise and I have tried everything they have given me and had injections until I was blue and the only thing that has helped me to dull the pain a little are opioids. Had I been younger maybe I could have held out a little longer because I was stronger. It’s not that I want them because I don’t. I hate every minute of it and sometimes ask myself why these young girls in some of the groups can’t fight harder not to have to take opioids instead of begging for them. Yes there have been seniors that have ODed on opioids but in most of the cases I have heard about it’s because they can’t get their medications for various reasons. Seniors should not have to punished for their years of working and their bodies slowly falling apart. I just want to live my final years with some kind of humanity in every day life