Distressed individuals fueling opioid epidemic, says journal article

One of the biggest lessons learned in the opioid epidemic is that patients taking the highest and most dangerous doses are the people who could be predicted to have poor outcomes, according to a recent article in Anesthesia and Analgesia.

This is what researchers have termed “adverse selection,” said journal author Jane Ballantyne, professor of anesthesiology and pain medicine at the University of Washington School of Medicine and an early advocate for restraining opioid prescribing.

Adverse-selection patients are those who have other conditions along with pain, including depression, anxiety, post-traumatic stress disorder, personality disorder, prior substance abuse disorder or a family history of substance use disorder, said Ballantyne. Her article is, “Opioids for the treatment of chronic of pain: Mistakes made, lessons learned, and future directions.”

“A core reason we have an opioid epidemic is that we are giving opioids to the wrong people,” she said.

As she explained, opioid drugs latch onto our natural opioid system, which regulates pain. With repeated stress, such as emotional trauma, the natural opioid system changes. Ballanytne said patients with repeated stress are more likely to develop chronic pain, not get much relief other than from opioids, and are much more likely to develop an addiction.

She said how to help these patients is debatable, but if they are given opioids long term, the likely trajectory is  towards addiction, which is a miserable state.

“My belief is that you cannot provide opioids safely to this population,” she said.

She also offers convincing evidence on why using opioids for chronic pain is fueling the epidemic.

She said a key lesson learned is that the body’s  own opioid system is incredibly powerful, and we need to be doing more to recruit this system.

“If you’re in the heat of battle, a soldier in war, you may be badly injured, but not feel pain all,” said Ballantyne. “This is the endogenous opioid system working. The pain transmitted and the pain you perceive is different.”

She said opioid drugs override that natural defense mechanism and interfere with a person’s ability to handle pain without drugs.

She said other cultures rely more on treatments that recruit the body's own opioid system, such as yoga, acupuncture, exercise, distraction, socialization, counseling and hypnosis.

“If we use opioid drugs, we are compromising all those ways people have used to control their pain through the millennia,” she said.

Apart from changing the way we think about and treat pain, she added, “the U.S. must now tackle how it should treat probably millions of people aready opioid dependent.”

Ballantyne said she was invited to write the article because she has been at the forefront of efforts to constrain opioid prescribing for chronic pain for many years. She was chief of pain medicine at Massachusetts General Hospital when she had a journal article published in The New England Journal of Medicine in 2003 saying that high dose opioids were harming people with chronic pain. She is also president of Physicians for Responsible Opioid Prescribing, She retired briefly but is now working at UW Medicine part-time.

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