- Misunderstanding opioids was not the major cause of the prescription opioid crisis.
- The more important cause of the opioid crisis was believing we could eradicate all pain and medicine alone was responsible for doing this.
- This philosophy evolved from the Scientific Revolution, replacing the idea that pain reflected sin and guided one to repentance.
- The new perspective proposed by the authors focuses on the psychological and social dimensions of the patient as well as the physical aspects.
A new book presents an important new understanding of chronic pain and the role of prescribed opioids—one that can help troubled patients and their distressed doctors alike. The Right to Pain Relief and Other Deep Roots of the Opioid Epidemic, Oxford, 2023, by psychiatrist, philosopher, and pain expert Mark D. Sullivan and anesthesiologist and pain expert Jane C. Ballantyne, argues that a change in our cultural concepts and values about pain and opioids created the opioid epidemic. They support this idea with a riveting historical and philosophical review.
Until around 1500 A.D., people understood "why" they had pain: God willed it in punishment for their sins. This led them to actively work to correct their sins to achieve salvation. From 1500 to 1700 A.D., this magical, all-powerful image of God gradually gave way to Deism, the idea that He no longer acted in the world after designing it, and that man must use his God-given potential to prosper. Humans could now thrive on Earth rather than achieving happiness only in the hereafter. This transition progressively broached the idea of pain as interfering with a good life; pain was no longer seen as necessary suffering.
After 1700 A.D., society extended this view: human fulfillment could occur during our earthly lives and reduction in pain and suffering was a desirable part of this. Pain had become escapable and something to be cured. This fit nicely with the influence of philosopher René Descartes and the burgeoning medical and scientific progress of the Scientific Revolution. Thinkers in this period sought to understand how pain occurred, and, understanding that, how they could cure it; answering "why" the pain occurred remained for the Church to inform. Society and the sciences evolved to view health as a prerequisite for happiness, and, rather than the Church, medicine became the arbiter and caretaker of physical pain.
The opioid crisis of the last 35 years derived from this new culture. More important than misunderstanding opioids, medicine adopted an approach that treated pain as a mechanical, medical affliction, one that framed pain as passive and innocent suffering. This reflected society’s belief in the right to full pain relief—but only for physical pain, the pain of psychosocial suffering was ignored. Nevertheless, a few believed pain treatment to be more complex, and established a proliferation of multidisciplinary pain clinics where psychologists and other pain specialists cared for the whole person. But this holistic approach would soon fall by the wayside.
Several societal events set the stage for what would become America’s effort to completely eradicate pain. Following the horrors of World War II, Western nations formed the United Nations, which published its Declaration of Human Rights in 1948; later amendments established the right to pain relief at the end of life, as did a U.S. Supreme Court decision. Influential international pain societies materialized and subsequently wrote that “access to pain management is a fundamental human right.”
Three specific advances then led to seeking complete pain relief in the U.S.: 1) The birth of anesthesia raised the possibility of complete relief of physical pain; for example, surgeons could now conduct pain-free dental extractions and amputations. 2) The palliative care movement advocated that those dying should not experience the additional burden of pain. 3) The Sackler brothers developed OxyContin, a much more effective narcotic than morphine, which had been used previously.
Tremendous efforts followed to promote opioid use for chronic pain using this rationale: if we could completely relieve pain in terminal patients and surgical patients, why not do the same for chronic pain patients. To achieve this, pain organizations, U.S. government regulators, and Congress promoted pain as safely relieved by opioids and advised its use.
Not surprising, the holistic, multidisciplinary model of managing pain by psychologists and other pain experts dwindled away, the pain patient’s high rates of depression and anxiety falling off the radar screen. This treatment took too much time and required specialists’ care, while opioids were easily-administered and produced rapid control.
Because of this, and vastly increasing numbers of patients seeking pain relief, chronic pain management increasingly devolved to primary care clinicians. (My earlier post describes their complete lack of training for this.) With unprepared clinicians understanding opioids as safe and effective and frantic patients demanding relief, the floodgates opened and massive prescribing followed—patients and clinicians deceived by the false hope of cure, only the pharmaceutical houses benefiting.
The authors review the now well-known research data (from nonpharmaceutical sources) that opioids caused great death and disability and had no beneficial impact on chronic pain.
But they go beyond the misunderstanding of opioids to the deep roots of the crisis. They explore how the pain-as-a-disease idea flouts the biopsychosocial model as well as modern learning models—both of which integrate the pain patient’s psychological and social features into treatment. The disease model overlooks that pain alone is not the problem, rather, it’s the emotion it generates.
In an extensive review of the evolutionary role of pain and its biological and neurological mechanisms, the authors explain how viewing pain as a disease amenable to opioid treatment was flawed. For example, evolution co-opted ancient brain pathways initially devoted to physical pain to also subserve psychological and social pain in much later evolving humans and other higher animals; this means that physical, psychological, and social features often co-occur in response to distress of any type in humans, that physical pain cannot be understood in isolation.
Additionally problematic, prescribed opioids commandeer our normal internal (endogenous) opioid systems to great detriment. Endogenous opioid systems not only mediate pain relief but they also mediate our stress responses, our moods, our energy, and our drives—our protective emotions and behaviors needed to function in society. Thus, they mediate socialization, the most important human task for survival in a complex society. Unfortunately, externally supplied opioids disrupt this system. Especially deleterious, the authors describe a deactivating effect of prescribed opioids where, “…the chronic opioid user will tend to look to further drug use for the positive effects of pain relief and reward, rather than to the more natural alternatives such as exercise, laughter, music, meditation, touch, close relationships, and friendships, all of which stimulate the endogenous opioid system.” As a result, chronic users lose their libido, energy, and drive and tend to passivity rather than action.
The authors then review the “salience network” (some call it the pain matrix). This alternative model of pain as a protective homeostatic emotion (rather than reflecting just physical damage) promotes survival via danger detection. Pain warns of danger to survival from threats at psychological and social levels as well as physical levels. Pain can stem from both personal and physical factors, similar to the causes of depression and anxiety. Centered about the anterior insula and the dorsal anterior cingulate cortices, the salience network integrates pain symptoms with other negative, protective symptoms, like anxiety and depression. It places the pain patient central to understanding what causes and relieves their pain—gauged by whether they interpret its meaning as dangerous or not. For chronic pain, this means the patient benefits from active participation in the care for their pain.
The salience network forms the basis of a meaning-centered model (degree of danger) for treating chronic pain. Unlike cognitive behavioral treatment, it does not focus on coping or managing one’s pain experience, nor does it aim to change the patient’s reaction to pain or to mitigate pain related suffering. Rather, it aims to decrease pain itself by changing the patient’s understanding of the pain mechanism. A 12-month study demonstrated improvement in the knowledge of pain biology as well as reduced intensity of pain and improved function. While new treatments work alone, they're even more effective when combined with comprehensive biopsychosocial rehabilitation programs.
The authors wisely conclude that medicine cannot address all human suffering. Nor can we abolish pain and suffering from human life. Failing to appreciate this represented an even greater misunderstanding than medicine’s use of opioids.
I had two issues with the book. First, I was concerned about the authors’ seeming ambivalence for the biopsychosocial model, at one point saying it had failed, while, at other points, pointing specifically to its value, and, throughout the book, emphasizing the need to integrate biological, psychological, and social facets of patients. Second, while some repetition was helpful in addressing this complex topic, I found it a bit distracting at times.
These concerns, however, are minor, and I heartily recommend this book. This new, not previously well-articulated concept can serve as the basis for a more effective and more humane approach to problematic chronic pain care. All clinicians, educators, and pain patients can benefit from reading this insightful, provocative book.