As Congress deliberates how to respond to the surging opioid epidemic, a number of bills have been introduced to support the development and Food and Drug Administration approval of a non-opioid pain medication. But the problem in American medicine is not a lack of alternatives to opioids, but the minimal utilization of the many non-opioid treatments for pain that already exist.
More than 200 medications other than opioids have evidence of benefit in at least some pain conditions. These range from the familiar (ibuprofen) to the surprising (gabapentin, an anti-seizure medication, that is FDA-approved for certain types of nerve-related pain). Yet most physicians are not aware how many medications other than opioids have strong evidence of relieving pain.
Beyond medications, many psychological and behavioral interventions have a substantial ability to reduce pain and improve function. Yet treatments such as physical therapy, cognitive-behavioral psychotherapy and yoga are prescribed far less commonly than opioids.
Why do so few doctors recommend non-opioid pain treatments? Opioid manufacturers’ ruthlessly effective (and in some cases, fraudulent) marketing has played a role, convincing many physicians to reflexively reach for the opioid prescription pad when confronted with pain. But other factors are also at play. Stanford University psychologist Beth Darnall, the author of multiple books on psychological approaches to pain relief, notes that “doctors literally get less pain medicine training than veterinarians. If they even know about psychological therapies for pain, they tend to view them as a last resort instead of the first option.”
Better training of physicians, who receive an average of only seven hours of pain management training in medical school, could thus help doctors expand their repertoire beyond opioids. Augmenting insurance coverage for physical therapy and pain-related psychotherapy could also help by stimulating more individuals to practice in those fields, which cannot meet the high level of patient need. “If you are referred to a pain psychologist by your primary care doctor, you might wait nine months for an appointment,” Darnall says.
If Congress simply supports the development of a new non-opioid pain treatment that, like all the others, rarely gets prescribed, it will do little to ameliorate the simultaneous problems of poorly managed pain and opioid overprescribing. It could have a much bigger effect by enhancing insurance benefits (e.g., in Medicaid and Medicare) for psychological and behavioral pain care services provided by interdisciplinary pain management clinics as well as funding training for pain management in medical schools and continuing education programs serving physicians and other health-care professionals.