Nor shall any man’s entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so. — Hippocratic Oath

Together, the prevalence of chronic pain and the increasing use of opioids have created a “silent epidemic” of distress, disability and danger to a large percentage of Americans. The overriding question is: Are we, as a nation, approaching management of chronic pain in the best possible manner that maximizes effectiveness and minimizes harm? — National Institutes of Health P2P Workshop, “The Role of Opioids in the Treatment of Chronic Pain”

A recent report by the NIH suggests that when it comes to the treatment of chronic pain, the medical profession may be very much in violation of what can be regarded as the first medical ethic: “First do no harm.”

Acute pain, if you will, is a bit of a no-brainer. Pain is a message that damage is occurring to our body, and we need to take action. From a medical perspective the physiology of acute pain is well understood; it’s associated with tissue damage and resolution of the pain is associated with healing of the injury.

Over the years, the medical profession has accumulated a vast array of therapeutic tools to combat chronic pain, though a cure still very much eludes us. One of those “tools” is opioid medication. Opioids include such medications as morphine, codeine and oxycodone.

In 1997, the American Academy of Pain Medicine, in an acknowledgement of the severity of the suffering of patients with chronic pain as well as our inability to provide many of these patients with acceptable solutions to their pain, issued a consensus paper endorsing the use of opioid medications for the treatment of chronic noncancerous pain. The Academy acknowledged that one of the problems with long-term use of opioids was addiction. In response, the medical profession began making the distinction between addiction and dependence. Addiction was defined as a craving for opioids with the intention of getting “high” as associated with drug-seeking behavior. Dependence occurred when an opioid medication was prescribed for medical reasons; a dosage was established where the pain was controlled, and the patient realized a significant improvement in the quality of their life. While the intention was noble, the consequences have been unacceptable.

Since then, the sales of prescription opioid medications measured in grams skyrocketed, Between 1997 to 2007, sales rose by 866 percent for oxycodone, 525 percent for fentanyl, 280 percent for hydrocodone and 222 percent for morphine. As reported in Pain Physician in July 2012, “Gram for gram, people in the United States now consume more narcotic medication than any other nation worldwide.” The report goes on to document that over 90 percent of patients taking opioid pain medications were prescribed these medications for the treatment of chronic pain .

The consequences of this explosion in the use of prescription narcotic medication for chronic pain have been horrific. In 2011, approximately 17,000 drug overdose deaths involved prescription opioid medications, and according to the CDC, “In 2007 there were more opioid analgesic deaths than overdoses involving heroin and cocaine combined.” While a significant number of these drug overdose deaths are associated with diversion of the medication to people who where not originally prescribed the medication, 60 percent of the deaths occurred in patients when they were given prescriptions based on the prescription guidelines by medical boards.

In addition to addiction, side effects from opioid medications include constipation, increased risk of birth defects, falls and fractures, heart attacks and a decrease in the production of testosterone. One other significant counter-intuitive side effect: In some people, opioids can cause hyperalgesia, a worsening of the pain.

While the NIH report offers a number of important policy and institutional changes to address this “silent epidemic,” I would suggest the basis of our problem comes from a lack of understanding of what we’re treating. Acute pain and chronic pain (not associated with on going tissue damage such as in cancer) are two very different phenomena in the body.

Unquestionably the evidence supporting the use of long-term opioids in the treatment of chronic pain is insufficient. What else needs to be done?

We need better studies to help us understand when the use of long-term opioid medications can be useful.

Physicians need to be better educated about the diagnosis and treatment of patients suffering with chronic pain

Ultimately, the use of long-term opioid medications is an admission of failure: our failure to be able to offer a cure or find other means of pain relief for an individual. These are medications of last resort.

Chronic pain is not a “thing” but one manifestation of a complex physiologic process that frequently impacts many body systems, including gastrointestinal, psychological, endocrine, and sleep. Treatment of individuals requires that we take a whole person perspective in our diagnosis and treatment, which requires a multidisciplinary approach.

In sum, as a pain specialist, I believe there is an important role for opioid medication, but that role should be limited. It should be prescribed only to selected individuals for the purpose of relieving pain and improving their quality of life when all other medical approaches have been exhausted, and then it should be very closely monitored by the diagnosing physician. Ultimately, the long-term use opioid medications is an admission of failure — it means we have failed to offer patients a cure or identify a less risky way providing pain relief to an individual. First, do no harm. Opioids should be medications of last resort.

Dr. Gary Kaplan, D.O., a pioneer of integrative medicine, is one of just 19 physicians board certified in both family medicine and pain medicine and practices in McLean, VA. A clinical associate professor at Georgetown University and director of the Kaplan Center for Integrative Medicine, he has also served as a consultant to the NIH and, in October 2013, was appointed to the Chronic Fatigue Syndrome Advisory Committee at Health and Human Services. He has discussed his work on Good Morning America, NPR, NBC News, as well as in The New York Times, The Washington Post and the Wall Street Journal. He resides in Falls Church, VA.

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The Problem With Opioids for Chronic Pain originally appeared on usnews.com