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Helping Patients Manage Pain While Curbing Opioid Addiction

Doctors need better training and better tools, including a range of alternatives for pain treatment

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Healthcare experts nationwide continue to plumb the deep, complex connection between pain and its treatment and opioid addiction in hopes of identifying more effective ways to reduce patients’ discomfort while curbing the growing epidemic of deadly substance use disorders.

New Jersey is already making progress in addressing substance abuse, according to several speakers at a conference Friday at Princeton University’s Center for Health and Wellbeing that further explored the nexus. But some doctors remain uncomfortable treating pain, opiates still abound, and too many pain patients still struggle to find relief.

The daylong “Pain, Pain Management, and the Opioid Epidemic Symposium” featured an academic and historical review of pain, reports on its connection to wellbeing, examples of alternative treatments, and a review of state and local policy developments to address opiate addiction. More than 250 million opiate prescriptions are written annually in the United States, experts said, and at least 20 million Americans are now addicted. Some 29,000 died of this disease in 2014.

The Nicholson Foundation is convinced that a better and more comprehensive approach to pain care can have a significant impact not only on the opioid epidemic but also more generally on healthcare delivery,” explained Jan Nicholson, president of the organization, which co-sponsored the event.

“This is a complex question and there are many different ways to take action,” noted Cecilia Elena Rouse, dean of Princeton’s Woodrow Wilson School.

Several speakers praised Gov. Chris Christie’s work to reduce the epidemic, including efforts to curb opioid prescriptions, prevent overdoses, improve access to treatment, and make recovery more successful. On Wednesday the governor met with addicts and caregivers at the Carrier Clinic in Belle Meade and pledged to continue working with recovery programs during the rest of his term and after he leaves office, in January 2018.

Dr. Arturo Brito, deputy commissioner for public health with the state Department of Health, said New Jersey has begun to benefit from a multiprong approach that involves law enforcement, healthcare, and social services and seeks to address addiction as a chronic disease and public health concern. These efforts have attracted more than $7.5 million in federal funding this year, he said, calling the support “a sign of how effective we’ve been over the last few years of working with multiple agencies.”

Much of this funding has come from the Centers for Disease Control and Prevention, which has responded to the crisis with additional research and new policies. This has included a revised set of guidelines for opiate prescribing, issued last spring, that takes a more preventative approach, encouraging doctors to avoid the addictive drugs when possible, use low doses if they do, and educate and carefully monitor those patients who do use these painkillers.

At the conference, the CDC’s Grant Baldwin stressed the connection between prescriptions, abuse, and mortality. “Opioid deaths have moved in lock-step with opioid prescriptions,” he said.

These methods are starting to take root in clinical settings. Mark Rosenberg, a doctor of osteopathy, discussed a program launched earlier this year at St. Joseph’s Regional Medical Center in Paterson -- the first of its kind nationwide -- that has cut opiate prescriptions in half. Emergency physicians use pain-blocking injections, patches, nitrous oxide, or other alternatives when possible, he explained.

In the past, Rosenberg said, “in my medical bag all I had was Tylenol and opioids, and this program was to give me more options.”

Dr. Rachel Evans, with the Henry J. Austin Federally Qualified Health Center in Trenton, said many physicians are uncomfortable dealing with pain treatments -- in part because they haven’t been well prepared in the past. “Primary care doctors are not well educated about this. We don’t have the right tools,” she said. “We just muddle along.”

To address this deficiency at Henry J. Austin, Evans said they have worked hard to train doctors to recognize addiction issues, employ evidence-based practices, and collaborate with others when they are unsure.

Poor training about opiates was the result of a lack of knowledge about how these powerful drugs worked, explained Dr. Jane Ballantyne, with the University of Washington Medical School. Physicians have also struggled to truly understand the underlying issues of pain and addiction, she said.

In the mid-1900s, drug dependence was considered a weakness of character, Ballantyne explained. By the 1970s, scientists had a better understanding of the physical aspects of addiction, but it was still viewed as a psychiatric condition well into the 1980s. By the 1990s, addiction research had improved, but a new focus on pain treatment -- fueled by the concept of pain as the “fifth vital sign” as well as new pharmacology -- unleashed a flood of opiates that has yet to recede.

Unfortunately, doctors were told that if these drugs were being prescribed for actual pain, the patient wouldn’t become addicted, Ballantyne added. “It was based on the idea that as long as you were treating pain (the patient) wouldn’t get the euphoria and wouldn’t be at risk for addiction,” she said. “And we were taught dependence was entirely physical and easy to reverse.”

In fact, addiction is far more complex than scientists first thought, Ballantyne noted, and withdrawal is dangerous and challenging. In addition, “we see so many patients now that never really get good pain relief and yet they are on massive doses of opiates,” she said.

The U.S. Surgeon General is also working to change how doctors treat pain.

Dr. Kathleen Foley with Memorial Sloan Kettering Cancer Care agreed many patients still face debilitating levels of pain and, as concern about addiction grows, they are having a harder time getting the medicine they need. Prescriptions are filled in part, or delayed, as a result of new regulations designed to reduce diversion of these drugs, and patients are feeling stigmatized.

“Physicians are hiding behind what the CDC said, not what the CDC meant,” she said. “There are unintended consequences of all the good things you’re trying to do.”

Sen. Joseph Vitale, (D-Middlesex), who chairs the Senate Health Committee and championed many of the laws that have allowed for new programs and reforms, stressed that the issue will require ongoing attention -- just like recovery itself. “This isn’t like a weird strain of the flu, here today gone next week, this is going to be here long term,” he said.

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