Opioid Therapy the Only Treatment Option Left Standing in Chronic Pain Debate

Although clinical psychiatrist Michael E. Schatman, PhD, CPE, formerly “beat the hell out of the opioid industry,” he spent an hour on the PAINWeek stage supporting his new belief that “maybe it’s time to stop fighting.”

“I’m not an opioid or a pharma guy, but I’ve got patients on chronic opioid therapy who are stable,” Schatman said during his “Just Saying No to Chronic Opioids For Noncancer Pain: Not Necessarily Good Medical Practice” presentation at PAINWeek 2013. Reinforcing that point, when Schatman asked if anyone in the audience had “never seen a patient do well on chronic opioid therapy,” not one hand went into the air.

But Schatman said that doesn’t mean long-term opioid therapy is the “perfect treatment” for chronic pain, as he noted that “the rates of bone density loss in patients is scary stuff,” in addition to more serious diversion and overdose problems.

Still, Schatman explained that the upsides to opioid treatment on a long-term basis become very clear after reviewing other options for chronic non-cancer pain patients.

For example, even though interdisciplinary chronic pain management programs have the strongest evidence-basis for most types of chronic non-cancer pain, the availability of those programs in the US has shriveled from more than 1,000 in 1998 to fewer than 100 outside of the US Department of Veterans Affairs today.

Proceeding to the option of spinal surgery, Schatman cited a wealth of sound medical literature — including studies co-written by surgeons — that found 90 percent of such procedures are not necessary, and he pointed out that the long-term evidence-basis for spinal surgeries is just as limited as it is for opioids. Examinations of interventional techniques for chronic pain turned up similar findings, as Schatman quoted two recent reviews concluding that injection therapy “lack(s) evidence for efficacy in treatment of lumbosacral and cervical radicular pain beyond a short period of time.”

Divulging that 40 percent of those who treat chronic pain are chiropractors — compared to 2 percent who are pain specialists — Schatman turned the spotlight onto chiropractic treatment options, which he said “contrary to myth, they are definitely not free of iatrogeneses,” as studies have detailed “cases of vertebrobasilar stroke associated with cervical manipulative therapy.” Schatman said the efficacy of acupuncture also doesn’t hold up in systematic reviews, and he offered seven references to prove it.

Officially out of plausible alternatives for treating chronic non-cancer pain, Schatman made strong arguments in support of long-term opioid therapy.

“Do we have the right as healers to ‘just say no’ to opioids, provided that the patient genuinely understands the potential consequences of chronic opioid therapy?” Schatman asked. “Should our fears of regulatory sanction interfere with our desires and obligations to reduce our patients’ suffering? Hiding one’s head in the sand is ok for ostriches, but it may not be ok for physicians.”

Schatman left his audience with a final thought that “there is no virtue associated with merely prescribing opioids to our patients with chronic pain; the heroic physician keeps an open mind, considers his/her patient’s well-being to be central, and does not let fear of the unknown get in the way of ameliorating suffering.”