The Post Opioid Era: A Call to Medical Psychologists

In April 2019, Dr. Cal Robinson, Ascellus’s Clinical Advisor, published an article in the Journal of Clinical Research in Pain and Anaesthesia published by Chembio Publishers that talked about what medical psychologists have learned about the opioid epidemic and what they should do going forward. The following is an abbreviated summary. You can read the entire article here.

For many years, medical providers approached pain relief from a biomedical-centered standpoint, over-prescribing opioids and raising usage to epidemic proportions. During this time, opioid analgesics were prescribed as the best way to treat patients with chronic pain. However, more than a generation later, we face what is called “the opioid epidemic.” This era of commonly prescribing opioids did not foretell the risk of opioid addiction, and as the number of addiction cases rose, it turned out that cases of addiction were under-reported. Indicating just how prevalent opioid use is in American culture, statistics show that while Americans make up five percent of our world’s population, we use 80 percent of the worldwide opioid supply. Twenty percent of American adults suffer from chronic pain, which is not only a major public health problem but also totals approximately $560 billion annually. We now live in the post-opioid era concerning pain management, as opioid analgesics are no longer sought as the initial treatment for chronic pain.   

Misplaced hope

Experienced psychologists, specifically medical psychologists, had hoped that with opioids, patients’ function and quality of life would improve. However, we’ve realized that this hope was misplaced and have determined that alternative therapy and non-opioid analgesics are a better plan. While knowledgeable of pharmacological intervention options, medical psychologists support the benefits of learning psychological skills because they know that they contribute to patients’ improved function and pain tolerance. It is important to provide patients behavioral interventions in order to increase their activity level. But this needs to be performed without increasing patient fears, which is not usually alleviated through prescription changes. 

Establishing guidelines

The opioid epidemic has created a generation of patients who have been prescribed opioids and expect them to provide pain relief despite the anodyne’s reduction in pain-relieving benefits once patients build up a tolerance. Because opioid-related deaths have risen within the last decade, clinical and legal guidelines have been established that define the proper use of these drugs. Consequently, the past decade has seen opioid prescriptions drop dramatically. Patients who have been using opioids on a maintenance prescription and are found that opioids are no longer considered appropriate for their treatment plan have been offered several other options: They are either weaned from the medications or transitioned to other non-opioid pain relievers and offered a recourse strategy for pain-reducing interventional procedures. Moreover, those patients who are prone to addiction are provided opportunities to aid in their tapering or weaning off the drugs. 

The psychological advantage

Chronic pain patients very often have medical appointments, multiple weekly physical therapy appointments, co-pays and laboratory fees. These appointments tend to overshadow pain or medical psychologist appointments, which are often viewed as less important. Not having the fiscal means to make an appointment with a medical psychologist also indicates that such therapy is thought to be irrelevant in light of other medical options. However, addressing psychological challenges is thought of as more demanding than merely filling another prescription. Promoting psychological intervention and deeming it as a worthwhile treatment is possible when the team of medical professionals recognize and support psychological treatment options. 

The efficacy of cognitive behavioral therapy

Chronic pain very often involves psychological challenges, with half of chronic pain sufferers experiencing the co-morbidity of depression and anxiety. “Psychological disorders and pain frequently co-occur and psychological factors are underappreciated and undertreated in the context of pain” (Darnell). It is well-known that cognitive behavioral therapy (CBT) is an effective, evidence-based therapy that reduces pain as well as catastrophizing, depression and disability. Chronic pain patients often linger on unpleasant thoughts regarding their pain and life experiences. This leaves them to focus on their hardship, feeling helpless and hopeless. This condition is referred to as pain catastrophizing, which is the most persuasive predictor for back pain disability, occurring one year after experiencing new-onset back pain. Known to alter brain structure and function, pain catastrophizing prepares a patient for pain responses as well as attention to future pain. But pain catastrophizing can be alleviated through cognitive-behavioral skills that teach patients to self-monitor and to employ effective methods for calming oneself. It is important to eliminate pain catastrophizing, as it impedes medical treatment and other interventions and conditions the brain to be attuned to increased pain sensitivity and distress. CBT effectively and successfully increases self-management so that the complications and discomfort brought about by fear can be ameliorated. 

Moving from struggling to acceptance

The evidence and advantage outcomes of pain-CBT demonstrate that patients can overcome chronic pain and come to a place of pain acceptance. With a willingness to accept and move forward positively with their pain makes patient action the focused goal of pain treatment. As Sullivan and Vowles state, “Restoring the capacity for meaningful action is what transforms someone with chronic pain from a patient into a person.” This is the kernel of effective chronic pain treatment and psychological intervention, which provides the means toward transformation.

Ascellus – Integrated Medical Case Solutions – is the premier behavioral medicine network for pain and trauma response with evidence-based outcomes and a proven track record for transforming workers’ compensation cases. Ascellus makes intervention efficient with a national network of 1,500+ psychologists and psychiatrists in all 50 states.