Chronic pain is a major public health problem that afflicts a significant number of patients, resulting in personal suffering, reduced productivity, and increased health care costs. A report from the National Academy of Medicine states that chronic pain affects approximately 100 million adults in the U.S. and costs the economy over $600 billion annually, a number which includes $300 billion in direct health care costs and a further $300 billion in lost productivity. Common chronic pain states such as low back pain, osteoarthritis, painful diabetic neuropathy, fibromyalgia, and headache are the leading causes of disability for individuals of working age. Dr. Najib Babul a prominent developer of medicines to treat pain, discusses some approaches to optimize relief from chronic pain and improve patients’ quality of life.
A wide variety of treatments are available for the management of chronic pain, including drugs, interventional management (e.g., trigger point injections, nerve blocks), surgery, psychological therapy, physical and rehabilitative therapy, and complementary and alternative medicine. The only consensus is that no magic bullet exists and for many patients, pain treatment needs to be multimodal, with two or more modalities working through different mechanisms of action to maximize relief.
Many drugs with different mechanisms are available to treat chronic pain, including non-opioid analgesics such as acetaminophen (Tylenol®), nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen (Advil®, Aleve, Celebrex®), duloxetine (Cymbalta®), pregabalin (Lyrica®), milnacipran (Savella®), topical local anesthetic patches (Lidoderm®) and NSAID patches (Felctor®). Additionally, many opioids have been approved to treat chronic pain, including oxycodone (OxyContin®, Xtampza ER, Troxyca® ER), oxymorphone (Opana® ER), hydromorphone (Exalgo®), hydrocodone (Hysingla®, Zohydro®), buprenorphine (Butrans®, Belbuca®), tapentadol (Nucynta®) and fentanyl patch (Duragesic®).
While all drugs to treat chronic pain have the potential to produce side effects ranging from mild and bothersome to severe and potentially life threatening, no class of drugs provokes as much controversy as opioid (narcotic) analgesics due to their potential for addiction in a minority of patients and their considerable adverse public health consequences when diverted into non-medical distribution channels for use by recreational drug users and opioid addicts.
Physicians need to carefully screen and exclude from treatment with opioid analgesics those patients who have a prior history of drug abuse, who are at higher risk for drug abuse or drug diversion, or who show signs of surreptitious drug use (e.g., positive random urine tests), There may also be a need to limit chronic opioid therapy only to those patients who agree to regular follow-up and who agree to also receive non-drug treatment, where appropriate. If the public health epidemic of pharmaceutically-sourced opioid addiction continues unabated, it may even provoke a campaign to restrict opioid prescribing to those patients who agree to participate in a national patient registry. Dr. Najib Babul cautions that attempts to curtail opioid abuse and diversion needs to be done without “criminalizing” the legitimate use of opioids in patients with chronic severe pain.
A common source of frustration for patients with chronic pain and their physicians is the inability to accurately predict the response to analgesics, thus necessitating an arduous trial and error to determine whether any treatment or combination of treatments provides benefit. To compound matters, although an integrative approach to chronic pain can be beneficial, rarely is such care available because most primary care providers have neither the training nor the resources to conduct a thorough pain examination and obtain a full pain, medical and psychological history. The National Academy of Medicine notes that despite over 100 million patients with chronic pain, there are only several thousand physicians who are board-certified in pain care and “fully four-fifths of people currently experiencing severe pain said they had never been referred to a specialized pain program or clinic.”
Dr. Najib Babul, PharmD, MBA is an accomplished pharmaceutical scientist, inventor, biotech entrepreneur and drug developer of medicines to treat acute, chronic, cancer and neuropathic pain, rheumatology, and cancer supportive care with more than 20 years of experience bringing new drugs to market. He has authored over 170 abstracts and manuscripts published in leading medical journals and scientific proceedings on a variety of subjects, including acute and chronic pain, opioid pharmacology, infectious diseases, psychiatry, clinical trials methodology and drug regulatory affairs. He currently serves as the Director of Medical and Pharmaceutical Consulting at the California Institute of Advanced Management in Los Angeles.
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