The Problem With Treating Pain in America

Chronic pain affects an estimated 100 million Americans, and between 5 to 8 million use opioids for long-term pain management. Data shows the number of prescriptions written for opioids as well opioid overdose deaths have skyrocketed in recent years, highlighting a growing addiction problem in the U.S. In response, the National Institutes of Health (NIH) released a report on Monday citing major gaps in the way American clinicians are treating pain.

In September, the NIH held a workshop to review chronic pain treatment with a panel of seven experts and more than 20 speakers. The NIH also reviewed relevant research on how pain should be treated in the United States. On Monday the NIH published its findings in the Annals of Internal Medicine, detailing a lack of research into better treatment methods and poor preparedness among physicians. “The prevalence of chronic pain and the increasing use of opioids have created a ‘silent epidemic’ of distress, disability, and danger to a large percentage of Americans,” the report authors write. “The overriding question is: Are we, as a nation, approaching management of chronic pain in the best possible manner that maximizes effectiveness and minimizes harm?”

The answer is no, the report reveals. The number of opioid prescriptions for pain has gone from 76 million in 1991 to 219 million in 2011, and according to recent Centers for Disease Control and Prevention (CDC) data, the latest figures show around 17,000 opioid-related overdose deaths in 2011. Between 2007 and 2010, the number of hospitalizations for opioid addiction increased four-fold. As TIME recently reported, the growing opioid problem means the nation also has a growing heroin problem, since both drugs offer similar highs, and heroin is cheaper and doesn’t need a prescription.

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Past addiction epidemics disproportionally affected non-white, low-income, inner-city citizens, but the current outbreak of prescription painkiller abuse is affecting mainstream white America. “[Past epidemics] made it easier for the public and even healthcare professionals to think about people with addiction as ‘those people,'” says Dr. Andrew Kolodny, the chief medical officer of the rehabilitation nonprofit Phoenix House. “Hopefully that’s changing.”

The NIH says that based on its assessment, healthcare providers in the United States are poorly prepared for managing pain, and many hold stigmas against their own patients seeking relief. “[Providers] are sometimes quick to label patients as ‘drug-seeking’ or as ‘addicts’ who overestimate their pain,” the authors write. “Some physicians ‘fire’ patients for increasing their dose or for merely voicing concerns about their pain management.”

For better care, the NIH says the medical community needs to start applying individualized treatment for chronic pain, and a multi-disciplinary approach should be used. Since pain is both physical and emotional and can affect all aspects of a person’s life, there should be more than one speciality involved in patient management. The NIH says there’s a lack of data that favors long-term use of opioids, and that other treatments like physical therapy and alternative and complementary medicine should be considered.

Clinicians do not have enough guidance when it comes to prescribing strategies, the NIH notes, arguing that the root of the problem is our overall lack of knowledge of how to effectively treat pain. The NIH says new study designs are needed to better research chronic pain treatment.

Critics of the response to the current opioid problem say a lack of federal attention has let the problem grow. “The opioid addiction problem didn’t begin under [President Obama’s] watch, but it’s gotten very bad on his watch,” says Kolodny. “There’s been 175,000 deaths over 15 years and the president cut funding to the National Institute on Drug Abuse, and he’s cut funding to Substance Abuse and Mental Health Services Administration for addiction treatment. I think the federal government is doing an awful job to tackle this public health crisis, with the exception of the CDC.”

The NIH says the challenge of when to use opioids and when to avoid them remains a question that available data can’t answer, and it’s a knowledge gap that needs to be filled as soon as possible. “For the more than 100 million Americans living with chronic pain, meeting this challenge cannot wait,” the report concludes.