The 'Silver Lining' of the Opioid Crisis: More Pain Research

Season Osborne

November 18, 2019

Congress has appropriated almost a billion dollars in 2018 and 2019 so that the National Institutes of Health (NIH) can address the opioid epidemic.

About half of that money is to address pain management, reported Charles Helmick, MD, who works on the NIH Helping to End Addiction Long-term (HEAL) initiative, which supports research into pain.

"Reducing prescribed opioids means addressing arthritis pain management," Helmick said during his ARP Distinguished Lecture at the American College of Rheumatology 2019 Annual Meeting in Atlanta.

It is projected that more than 78 million adults in the United States will have arthritis by 2040, he reported. It is the country's leading cause of disability, and cost Americans $304 billion in expenses and lost wages in 2013.

One of the reasons chronic conditions like arthritis don't get the attention that other diseases do is that mortality is a driver of research, which is a problem, said Helmick, who is the scientific lead for the arthritis program at the Centers for Disease Control and Prevention.

But there has been an evolution in the visibility of arthritis as a public health concern. "The silver lining" of the opioid epidemic might be that pain management finally gets the attention it deserves, he explained.

About half of all patients with arthritis experience persistent or chronic pain, and 15 million experience severe joint pain, which can be debilitating and make everyday tasks difficult to perform, affecting quality of life.

The fallout from the opioid crisis is that opioids — once considered the most effective way to manage pain — are no longer commonly prescribed.

Our understanding of pain continues to grow. And the more we learn, the more we realize how multifactorial pain is.

"Pain is complex," said Brett Smith, MD, a rheumatologist at the Blount Memorial Physicians Group in Alcoa, Tennessee. He pointed out that sleep disruption, anxiety, and obesity can play a role in the way individuals experience pain.

In the medical community, "our understanding of pain continues to grow," he explained. "And the more we learn, the more we realize how multifactorial pain is and how multifaceted the approach needs to be for optimal outcomes."

The nature of pain determines how clinicians treat patients, but Smith said he always recommends physical exercise, noting that low-impact exercise, such as walking, swimming, and cycling, increases strength and flexibility and can reduce pain.

It is difficult to get people in inflammatory pain to exercise, Smith acknowledged, but a steroid injection can help get patients started with an exercise regimen to strengthen muscles and reduce pain in the longer term.

People with noninflammatory chronic pain typically see improvement with regular yoga or meditation, Smith said, adding that acupuncture can help some patients.

Joint pain often occurs in conjunction with other chronic diseases, such as diabetes and heart disease. Obesity raises the risk for arthritis and generally makes arthritis worse. Smoking contributes to inflammation and has been linked to rheumatoid arthritis.

A multidisciplinary team approach — with general practitioners, rheumatologists, psychologists, pain specialists, and physical and occupational therapists — can be used to address the various factors that contribute to pain. And programs that offer guidance on healthy lifestyles, including advice on diet and smoking cessation, can benefit many people, Smith said.

"Clinicians may be able to refer their patients to lifestyle-management programs that are difficult to provide in the clinic but are available in the larger community," Helmick added. "More community-based interventions — like physical-activity programs and self-management education workshops — have become available to patients, and can help them do all the things that are recommended for their arthritis."

A cultural transformation is needed in the way society thinks about pain. "In the patient population, a lot of people think that the important outcome is to have no pain," Helmick said. "That's not realistic."

According to the pain community and the national pain strategy, "you really want to have a level of pain that is manageable, that allows you to do the things you value in life." Helmick said. "That's what the public needs to think about, rather than getting rid of all pain."

A quick fix for pain doesn't exist. "We need to reprioritize a healthy lifestyle," Smith said, citing a Mediterranean diet, aerobic exercise, adequate sleep, and stress-coping strategies. "People have to be motivated by thinking, 'I'm going to have more energy and less pain if I do these things'."

American College of Rheumatology (ACR) 2019 Annual Meeting. Presented November 11, 2019.

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