Fear Of Addiction Means Chronic Pain Goes Untreated

The FDA's decision to approve a new painkiller has met with fierce opposition. Judy Foreman, author of A Nation in Pain, tells NPR's Scott Simon why pain relief is such a highly polarized subject.

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SCOTT SIMON, HOST:

The debate on approving new drugs to treat pain can sometimes get as polarized as abortion or gun control, as the number of people who become addicted or who have died from overdoses of legal painkillers increases. Several states are now trying to ban Zohydro, the newest FDA-approved painkiller. If you're a patient from who suffers from chronic pain and live in a state with regulatory barriers, it can be nearly impossible to get a doctor to prescribe anything for long-term relief.

An epidemic of abuse, as well as fear, means that pain is going untreated, says medical journalist Judy Foreman. The author of "A Nation in Pain" believes that it's not only cruel, but unnecessary. Judy Foreman joins us from Boston. Thanks so much for being with us.

JUDY FOREMAN: You're very welcome.

SIMON: There were complaints for years that doctors were handing out painkillers like candy; and now, there are complaints that doctors don't like to prescribe anything stronger than an aspirin. What's changed?

FOREMAN: Well, you know, the whole pendulum has gone back and forth for decades. We haven't been able to really ever get it right, in my opinion. And it's really been very tough on pain patients who legitimately need the medications. And at the same time, the more prescription opioids there are floating around out there, the more people who are inclined to - or feel they need to - are abusing them. So it's colliding epidemics.

SIMON: I read a lot of material that suggests that there's got to be a way better than opioids in any case.

FOREMAN: Yeah, opiods are not fantastic drugs, when you get right down to it. They only really reduce pain about 30 to 40 percent. And that matters if your pain is a 10 on a 10-point scale, and you can knock it down to a 6 or 7. But that doesn't really totally get rid of the pain.

So we absolutely need better things. And there are some better things, or some nonpharmacological things, already on the market and available to people, including things like acupuncture and massage and nonsteroidal anti-inflammatories - although they cause a certain number of deaths every year, and acetaminophen - and that causes something like 30,000 hospitalizations. So there are other things but clearly, we need something better.

SIMON: Let me ask you about Zohydro. Gov. Patrick, of Massachusetts there, calls it - and I quote - "a potentially lethal narcotic painkiller." Twenty-nine states have asked the FDA to reconsider its approval. Are they wrong, in your judgment?

FOREMAN: Yes, they are. And it's very complicated, but the FDA did do a big study of Zohydro and concluded that it was safe and effective. The big benefit of Zohydro is that unlike a lot of other drugs on the market, it's just a single-agent thing. It just has hydrocodone. It doesn't also have acetaminophen. And even though it's sort of hard for laypeople to understand, it's the acetaminophen, which is the active ingredient in Tylenol, that actually is the dose-limiting thing about a lot of combination medication. So I do think it's good to have Zohydro available to people.

SIMON: You've written that serious chronic pain is a bigger problem than cancer - and for that matter, cancer, heart disease and diabetes combined.

FOREMAN: And you can even throw in AIDS. There are more people suffering from chronic pain than all those four other things put together. That's 100 million American - American adults, by the way; not kids, not people - military returning from the wars, or even people in nursing homes. So that may actually be an underestimate. That figure comes from a report in 2011 from the Institute of Medicine. They're not all in excruciating, debilitating pain, but an estimated 10 to 30 percent are. So that's a lot of people.

SIMON: Well, help remind people what that means for someone's life.

FOREMAN: Oh, my God. Some people can't get out of bed, or they can't walk. Many people get very depressed, and it really is a life-wrecking thing. And in some cases, it's a life-ending thing because what a lot of people don't realize is that the suicide risk among people in chronic pain is twice that for people not in pain.

SIMON: And what is the line - and I suspect there's no clear answer on this - between dependence, somebody who needs something for chronic pain; and addiction?

FOREMAN: Yeah, that's a great question. There are some doctors who are in the very anti-opioid camp who think that that's a distinction without a meaningful difference. But more doctors believe that it is an important difference. Addiction is defined as a neurobiological condition where people use the drugs compulsively. They use them despite knowing they're doing harm.

Physical dependence is different. If you go on opiods for even two or three weeks, you will become physically dependent. That's 100 percent guaranteed, but that's not the same as addiction. That is a state of adaptation that your body makes to the opioids. It means your opioid receptors in your nervous system are full of the drugs. So that can be dealt with and often, it is - after surgery or after...

SIMON: Yeah.

FOREMAN: ...Lots of medical interventions...

SIMON: People routinely will take painkillers for a month or so after surgery.

FOREMAN: And get off them without making any headlines at all.

SIMON: When you survey the medical world, Ms. Foreman, does it seem to be divided between people who perceive addiction as the great danger, and those who perceive pain as the great danger?

FOREMAN: Yes. Unfortunately, it's become very, very polarized. You're either for the pain patients, or you're for the addicts. And that seems crazy because among other things, there a number of people who have both chronic pain and addiction. And of course, those are the patients who have the hardest time. Doctors want to run away from them because they just really don't know quite how to manage the pain without triggering an addiction. So yes, we need more people who really do understand both. And there's an argument to be made that both should be taught at the same time in medical schools.

SIMON: Judy Foreman, who is the author of "A Nation in Pain," speaking to us from studios on the campus of Harvard University. Thanks so much for being with us.

FOREMAN: Thank you.

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