Responses to the Opioid Crisis Must Account for People Who Experience Chronic Pain

A woman studies to become a pharmacy technician in Cleveland, Ohio, February 2012.

This column contains a correction.

“Opioids fill the news with a steady stream of stories of lives lost from overdose and abuse. What we rarely hear is the other side—opioids are also the most powerful pain medication we have.” — Kate Nicholson, civil rights attorney and chronic pain survivor

It’s common knowledge that the United States is in the throes of an opioids misuse crisis. Lethal opioid overdoses—which are increasingly more likely to involve heroin and illegally made synthetic drugs than prescription painkillers—claim the lives of 115 people every day and have taken an enormous toll on individuals and communities alike across the country.* But as policymakers at all levels of government continue to debate efforts to address opioid misuse, the basic needs of people who use opioids appropriately and rely on them to function have fallen by the wayside. The result is that individuals who live with chronic pain have been deprived of needed painkillers—even though prescription drugs are not behind the spike in lethal overdoses.

Opioids are a lifeline for many who live with chronic pain

Chronic pain is an expansive term that covers a diverse range of experiences with many causes—and is the primary cause of disability in the United States. Many who experience this type of pain rely on opioids in order to manage that pain and to participate to the fullest extent possible in everyday activities and in public life. As of 2012, more than 1 in 10 adults in the United States—or 25.3 million people—live with chronic pain. The incidence of chronic pain climbs with age: 42 percent of adults ages 65 and above experience it, which means that, as the population ages, the United States will be home to an ever-larger proportion of people with chronic pain.

The consequences of unrelieved chronic pain are serious. It takes an enormous toll on one’s mental health: Major depressive disorder, suicidal ideation, and suicide attempts are each associated with chronic pain. It remains the second-most common medical cause of suicide, after bipolar disorder. Chronic pain disrupts sleep, is a predictor of cardiovascular health issues, and, moreover, interferes with social interaction and employment status.

For many of these individuals, opioids have provided a lifeline, and much-needed relief from chronic pain’s severe consequences. In 2014, between 9.6 million and 11.5 million people were prescribed opioids for longer-term use. These painkillers help many individuals to remain at work and to participate in everyday activities with family and friends, as well as allow them to live independently.

To be sure, opioids are not appropriate for everyone who faces chronic pain. Many people report little to no relief from any kind of pain medication, and a recent study found that for some people, generic Vicodin, oxycodone, and fentanyl patches were no more effective than nonopioid painkillers. However, for many individuals who experience chronic pain, opioids deliver much-needed relief.

It’s no coincidence that efforts to reduce access to opioids are associated with a spike in suicide rates—and importantly, not with a decrease in lethal overdoses, per a preliminary abstract from the U.S. Department of Veterans Affairs. And it makes sense: Today, the main driver of the opioid epidemic is not prescription misuse, but rather illegal access to fentanyl and heroin, to which people who misuse opioid prescriptions rarely transition. Meanwhile, lethal overdoses from certain prescription drugs such as oxycodone and hydrocodone have been in steady decline since 2011.

Some efforts to address substance misuse have had dire unintended consequences

Since 2016, some 28 states have enacted policies that place some sort of limit, guidance, or restriction on opioid prescriptions. Massachusetts became the first of these states when it restricted first-time opioid prescriptions to no more than seven days’ worth of pain relief. Many states have followed suit, and some have sought even harsher limits on supply. Florida, Kentucky, and Minnesota, for instance, allow just three to four days’ worth of opioids, while others, such as Rhode Island, have implemented limits on the very dosage that patients can receive.

Although most states have sought to exempt people who experience chronic pain from these laws, in practice, many individuals who live with chronic pain have been denied coverage or refills by insurance companies and pharmacy policies that use such laws to withhold such services. Furthermore, physicians have begun to refuse opioid prescriptions in droves and, in many cases, to wean patients off of stable opioid regimens prematurely.

The result is that needed pain medications can become burdensome or even impossible to obtain, and pain relief remains out of reach for a great many who need it. People are forced into withdrawal or have to travel from pharmacy to pharmacy to see which will provide them needed medication. Many resort to hospitalization or emergency rooms, and some die prematurely and sometimes—as previously noted—by suicide. Inability to access needed prescription opioids not only significantly undermines one’s quality of life and relationships; it also takes an economic toll, as severe and uncontrolled pain makes it enormously difficult for people to participate in the labor market.

Given this country’s long history of stigma around pain that cannot be seen—particularly that which affects women and black people—the fact that policymakers and private entities have allowed the needs of people with chronic pain to fall by the wayside comes as little surprise. Indeed, women—who are more likely to experience chronic pain in general, as well as to experience it at greater intensities and for longer periods than are men—are routinely denied adequate treatment by medical professionals, who believe their discomfort to be psychogenic. Black emergency room visitors, due to a combination of institutional racism and individual bias, are also frequently faced with indifference and are half as likely to be prescribed strong narcotics by physicians for pain mitigation as are their white counterparts.

Conclusion

The plight of these individuals must not be viewed as inevitable collateral damage amid the nation’s response to the opioid epidemic. Policies that limit access to opioid supply for people with chronic pain have already begun to fuel another, much quieter public health crisis in the United States—one that has left people in poorer mental health, with a diminished quality of life and in unrelieved and relentless pain.

Eliza Schultz is the research associate for the Poverty to Prosperity Program at the Center for American Progress.

*Correction, June 14, 2018: This column has been updated to accurately specify the types of synthetic drugs involved in lethal opioid overdoses.