Interviewer: By focusing on the opioid epidemic, are we missing the bigger problem? We'll talk about that next on The Scope.
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Interviewer: Mark Ilgen is an associate professor at the Department of Psychiatry at University of Michigan, and much of his current work focuses on improving treatment outcomes for patients struggling with substance abuse disorders that are also complicated by co-occurring problems like chronic pain. Dr. Ilgen, when you say that to really solve the opioid problem that the conversation needs to be about a bigger issue, can you tell me what you mean?
Dr. Ilgen: The topic of opioid use and opioid overuse has received a lot of attention in the national media. You often hear about what's often called the "opioid epidemic" as something that's grown within the last 5 or 10 years, but prior to even the last 7 to 10 years, there was still the problem that many individuals with pain were not functioning well. And a large portion of those individuals coped with their pain by misusing or overusing substances, and that's not limited to opioids.
Someone can drink too much to manage their pain, use marijuana to manage their pain or overuse marijuana to manage their pain, or use either street or prescription opioids. And so the broader issue of pain management has, in some ways, been lost. And there's really a lot of concern that in our conversation about, "How do we keep people safe from opioids," that we might also be losing sight of the fact that many people still have chronic and poorly-managed pain. And those individuals are often left without a lot of very attractive treatment options.
Interviewer: So what can you do? What is the bigger solution to the problem?
Dr. Ilgen: I think that pain management as a topic is one that I think we need to be giving more attention in our health care system, so it's a difficult topic for a lot of treatment providers to discuss. And I think a big part of why opioids became the problem that they are now is that they presented or were, in some ways, billed as a solution and as an easy solution to the problem of pain. And so that was appealing to primary care physicians and other treatment providers because they felt like they could do something to help someone who was struggling with chronic pain.
But a true, honest conversation about chronic pain requires going into more depth, understanding what the patient's going through, getting better diagnostic information about the pain, and then coming up with coping strategies that are more comprehensive that go beyond what you can usually achieve with a medication.
Interviewer: What are some of the solutions that you're seeing out there that are offering some promise?
Dr. Ilgen: Well, the hard thing with . . . it's a very complicated issue, and the solutions to pain are going to look very different, depending on the nature of the chronic pain. So again, unfortunately, for a long time, the solution to chronic pain was often pitched as opioids, and those were applied across a number of chronic pain conditions, from fibromyalgia to migraines to lower back pain.
But in fact, the different solutions to the pain conditions often really vary substantially, depending on what the presenting problem is. So a first step in doing something about the pain is just to make sure you get an accurate diagnosis, and in many cases, that means going to a pain specialist and getting a better sense of what's actually going on.
And for a lot of individuals who have musculoskeletal pain, they need forms of treatment that focus on their physical functioning as well as their pain level. And most effective treatments for long-term, let's say, back pain involve both helping the person manage the pain in the moment, but also helping them remain active in their life, get physical therapy, in some cases get certain pain-specific types of psychotherapy that help them cope with their pain and better adapt to the pain condition.
Interviewer: And to some extent, I would imagine one of the challenges, too, is helping us, as patients, overcome this notion of the easy solution of the pill, like the pill or the painkiller is the ultimate thing. Because physical therapy and staying active, all that stuff take commitment and work, and people can also be skeptical that that's actually going to do anything.
Dr. Ilgen: Exactly. I think managing expectations around what is or isn't possible is very important, so unfortunately, often the case, that you don't have an easy solution to the pain. Instead, you're looking at scaling back on the pain from a level that really is impairing to a level that's easy to cope with. But it often doesn't go away. It's just at a lower and more manageable level.
Interviewer: Yeah, so as a patient, suffering from pain from a particular condition, it sounds like your recommendation be, first, make sure that I have an accurate diagnosis of what's causing that pain. So then that would lead to the ability to come up with a plan to help manage that pain, which comes back to your concept of it might not go completely away, but you do what you can do. And then, at that point, just realize that it's a process, and it's going to take some time, and maybe that's a good trade-off for the downside of a potential addictive substance that could ruin your life.
Dr. Ilgen: Yeah, and I don't want to overstate the potential downsides of opioids. So there's a lot of controversy in the field about whether opioids are ever an effective and appropriate treatment for chronic pain, and then, if so, at what level? And I think those decisions are just made on a case-by-case basis with a treatment provider.
What we see that's problematic is when someone is taking a moderate or high dose of an opioid and not getting a lot of relief and then ends up escalating and needing a higher dose to get some relief and then even that's not working, that's when someone's kind of going down a path towards not getting a lot of return on the medication. It's not really giving them a lot of pain relief, and the risk for side effects is going up.
And that's when you really want to be concerned and be careful and to stop and have a really frank conversation with your treatment provider about, are you on the right path here? Or are you really getting greater and greater physical dependence on the medication for either continued not-very-good or maybe, in a lot of cases, a worse degree of pain relief than you did initially?
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