Justifying Pain Management: Chronic Pain Patients and Opioid Prescribing Restrictions

Since April of this year, I’ve been conducting fieldwork for my Master’s in anthropology. My research is focused on how chronic pain patients are able—or not—to access opioids to manage their pain in light of the Guideline for Prescribing Opioids for Chronic Pain published by the Center for Disease Control in 2016 (Dowell, et al). My central questions revolve around uncovering how these guidelines may have altered pain patients access to opioids, and how any changes are affecting their everyday lives. As a chronic pain patient myself, I am very aware of just how life-altering changes to your prescribing routine can be. In talking with other chronic pain patients, I’ve tried to understand how these guidelines have altered their lives. Broadly, I’m trying to understand how the opioid epidemic, CDC guidelines, and chronic pain patients are knotted together—and what that knotting reflects about America’s history, perceptions, and policies around drugs and those who rely on them.

Put forth as suggestions, the CDC’s guidelines have been taken up by biomedical practitioners since their publication in ways that, according to a recent news report, the CDC now acknowledges may be causing unnecessary harm. I have heard from my interlocutors that these guidelines have been quoted to them as justification for forcibly taking them off opioids—despite being on stable doses, without abusing their medication, for years. Chronic pain sufferers I’ve spent time with have described how being forced off opioid medications led to their inability to engage in activities they formerly found simple—walking their dog, for instance. Many have talked about their inability to participate in much more than short bursts of mild activity—getting up, getting dressed, eating breakfast—followed by having to rest. Holding down a job has become impossible for some, leading to depression and anxiety about their place in life, in their family, and in their relationships with partner and friends. By discontinuing chronic pain patients’ access to opioids, their ability to do the things they feel define them as a person has also been lost.

The CDC’s opioid prescribing guidelines have had an undeniably deep and often negative impact on the lives of chronic pain patients. The guidelines were designed as a response to the public health crisis of opioid addiction and, most urgently, statistically rising opioid overdose deaths, which had been linked with a rise in opioid prescriptions since the mid-1990s. In practice, the guidelines have, however, rendered an already vulnerable and precarious population even more vulnerable and precarious. Pain prevents them from working and participating in social relationships, leading to economic instability and isolation. Further, based on more recent statistics, opioid overdose deaths are not decreasing along with the falling number of prescriptions. They are, conversely, rising. According to 2018 data from New Hampshire, fentanyl accounts for 161 overdose deaths, and fentanyl and other drugs (excluding heroin) account for 119 deaths. Heroin is responsible for precisely one death, and “other opioids” for 13 deaths. Considering that these fentanyl deaths are generally due to the illicitly manufactured and acquired variety, prescription opioids accounted for an incredibly small percentage of opioid overdose deaths in New Hampshire last year.

Recently, The President’s Commission on Combating Drug Addiction and the Opioid Crisis identified 30 or more factors at work in the formation of the current opioid crisis (Madras, et al, 2016: 943). While the healthcare system is listed as one of these factors, opioid prescriptions are not solely responsible for the continuously rising numbers of opioid addiction and overdose deaths. No one is denying that overdoses do happen, or that prescription opioids have played a role in some of those deaths, but what I hope to show when I sit down to write my thesis is that there is much, much more at work in this “opioid crisis” than CDC statistics can tell us. Another recent study on drug overdose deaths spanning several decades addresses what its authors call the “drug overdose epidemic.” The authors trace a steadily increasing rate of overdose deaths back to at least 1979, of which the opioid crisis is the current manifestation (Jalal, et al, 2018). A deeper examination of the data that these and other researchers have begun to collect and publish will allow for an exploration of the temporal, social, and geographic locations and forces at play in this American drug overdose epidemic. Hopefully, it will also help bring perspective to the medical, legal, and governmental view of opioids in relation to the treatment of chronic pain.

There are, of course, deeper and broader questions that this data raises. What factors might have been and are continuing to work on the steady increase in drug overdose deaths here in the U.S.? How might governmental policies about drugs and drug use, and government-initiated situations like that created by the War on Drugs, be part of the reason for the increase in drug use and drug overdose deaths? If we approach drugs, their use, and abuse over the course of U.S. history, what other trends and themes might emerge? How might drugs and drug use—the fluctuating popularity and prevalence of specific drugs during specific time periods—speak to broader issues in a particular era of American history? Histories of structural inequalities could also be explored through an analysis of this data, which surely has implications for understanding how social, economic, racial, and gender disparities are at work in drug use.

For the chronic pain patients I have been spending time with these past 9 months, a nuanced perception of drug use and drug overdose deaths would, I hope, help bring perspective to their use of opioids to manage pain.

During my fieldwork, while exploring the issues faced by chronic pain patients in accessing opioids, I began to ask other questions and wonder about other possibilities. Illuminating the way chronic pain patients have been caught up in the current drug epidemic is one avenue I am concerned with. How chronic pain patients, the opioid epidemic, and the War on Drugs are knotted together has also been on my mind. More recently, I’ve become interested in the ways that chronic pain patients, and chronic pain patient groups, are engaging in political action with the intention of affecting policy decisions about opioid prescribing. All of these things relate, broadly, to what Adriana Petryna, Nikolas Rose, and a host of others, have called biocitizenship. Looking at the way the chronic pain patients I speak with are negotiating access to opioids can provide some insights into the way ideologies of biocitizenship are manifesting in contemporary American society, and what the limits of that biocitizenship might currently be.

This being anthropology, these are questions I am exploring using the many, many hours of interviews, piles of fieldnotes, and journal entries I’ve generated. Sitting down with this mass of data and attempting to select particularly impactful, pointed, and poignant parts is no small task in and of itself. Fitting all of these parts into a whole, through which I hope to shed light on both the plight of individuals with chronic pain and some of the underlying structural issues at work in creating the position they find themselves in seems, right now, a near-impossible task. In the end, I hope that by relating the stories of the people I’ve come to know I can stimulate a more nuanced discussion of what opioids mean to those chronically in pain, for whom these medications grant the ability to live their lives with meaning and purpose.

Dowell D, Haegerich TM, Chou R. 2016. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.

Jalal, Hawre, et al. 2018. “Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016.” Science: Vol. 361, Issue 6408, eaau1184
DOI: 10.1126/science.aau1184

Madras, Bertha K., et al. 2018. “The President’s Commission on Combating Drug Addiction and the Opioid Crisis: Origins and Recommendations.” Clinical Pharmacology and Therapeutics: Vol 103, Num. 6.

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9 thoughts on “Justifying Pain Management: Chronic Pain Patients and Opioid Prescribing Restrictions

  1. As a home care nurse and former ER nurse, I have seen and continue to see patients with both chronic pain issues and acute substance abuse issues that have lead to ODs. It is an interesting subject from the nursing perspective. It is felt that this problem is of our own making in a way because pain became referred to as the 5th vital sign and pain control was made a significant issue in patient care. These problems seem to be the “fruits of the health care”’s labors.

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  2. Thank you for doing this research – no one else seems to be evaluating the consequences of the CDC guidelines. Since those were issued there has been zero study of the consequences.

    No one wants to count the resulting pain patient suicides because that would make obvious the absurdity of restricting opioids for pain patients while doing nothing about the overdoses happening from multiple street drugs. We pain patients are not the ones overdosing, illicit drug users are, yet they keep going after us as overdoses continue rising.

    The current “opioid policies” are not only ineffectual at preventing overdoses but are destroying the lives of uninvolved parties, yet there are no efforts to study the results. I hope your paper will point out this truth that no government agency wants to know.

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    1. Thank you – I hope that what I’m doing now can serve as a starting point for getting more people to look seriously at the consequences of forcibly taking chronic pain patients off opioids

      The suicides need to be talked about – so do all of the ruined lives. People in pain already have to suffer, already are afraid of what today, tomorrow, next week might bing in terms of their pain level and attendant ability to function. We shouldn’t have to fear the doctors who are supposed to help us. Supposed to, I used to think, help us live the best lives we can despite the pain. Taking our medications away as part of what feels like a blind crusade to reduce the number of opioids prescribed does nothing, from what I have heard and seen and experienced myself, to improve our quality of life.

      This paper will just be the start. I’ll be undertaking several more years of reseach for my PhD and will be able to build up a larger group, gather more experiences, and make a bigger impact. I feel like right now we might be approaching a tipping point – if we’re loud enough and insistent enough and don’t just go quietly away and sit in the corner. I want the work I’m doing to be part of our collective demand to be treated as valuable human beings whose lives – the quality of our lives – matters.

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    1. Of the about 15 people I spoke to, all but one had experienced forcible dose reductions, had their meds cut off, been forced to undergo procedures/treatments they didn’t want and didn’t benefit from just to maintain the meds they did get. Because of the time constraints on getting my fieldwork done for my MA, my sample size was relatively small. However, it’s quite remarkable that out of all the people I did speak to, only one person hadn’t experienced problems getting their medication. They did, though, have to drive over 2 hous away to see the only doctor they’d been able to find who would prescribe without forcibly tapering them – so far.

      Once I start on this again during the summer and will have more time and resources to work with, and so will be able to talk to more people, I wouldn’t be surprised to find that the ratio of reductions to no reductions stays the same – or even shrinks.

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      1. Yes, thank you, that would be very helpful! My email is amanda.votta at gmail.com I am hoping to talk to more people aound the country for this. Especially in states with stricter regulations than MA has – which is where most of the people I’ve talked to are.

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