Not everything is known about the optimal approach to treating opioid addiction or chronic pain, but a diverse panel on the opening day of the Rx Drug Abuse & Heroin Summit tried at least to advance some critical components. The message seemed to be that communities cannot simply wait for the research to catch up to an epidemic that one panelist referred to as the nation's leading killer of adults under age 50.
For Kelly J. Clark, MD, founder of Addiction Crisis Solutions and immediate past president of the American Society of Addiction Medicine (ASAM), an important element should involve acknowledging that one cannot talk one's way out of an opioid addiction (as in talk therapy), and that medication holds the key to saving lives. “This is not up for any further reasonable medical debate,” Clark said.
For R. Corey Waller, MD, principal of Health Management Associates, the treatment of both addiction and chronic pain requires individualized assessment and treatment, and a commitment of time. Providers in both the addiction treatment and pain management communities too often try to shoehorn every patient into their particular approach to care, said Waller, who consults with state governments on treatment system redesign.
Sounding a theme that has been prevalent at past years' opioid summits and most certainly will be again this year, the former commissioner of the Tennessee Department of Health advocated a balanced response to the opioid crisis with heavy doses of treatment, prevention and control. “Treatment is essential, but we're not going to treat our way out of this epidemic either,” said John Dreyzehner, MD, MPH, an occupational medicine physician and public health consultant.
Dreyzehner sounded the most cautious tone about the state of the knowledge base, even acknowledging the limitations of strategies that were adopted in Tennessee that included tighter regulation of pain management clinics. “Regulation is a weak safeguard at best,” he said.
He also pointed out that a 2018 journal article from National Institute on Drug Abuse (NIDA) director Nora Volkow, MD, cited numerous research gaps that hinder the identification of effective treatment, in areas from the comparative effectiveness of various approaches to an understanding of when an inpatient or outpatient care level of care becomes the better option.
Steven Stanos, DO, medical director of Swedish Pain Services in Seattle, generally called for a more interdisciplinary approach to pain management that doesn't rely as heavily on medication. Physical therapy, psychological counseling and relaxation training all can be important components of a treatment plan that also seeks to teach patients more about anatomy and physiology, Stanos said.
Capacity needs across the board
“We have to build capacity at all levels of care,” Waller said. In too many communities, the effort has focused on building one program, often with the goal of expanding capacity to prescribe agonist medication for opioid addiction. Case management and access to treatment for comorbid mental health issues are equally important, he said.
“Then we have to build competency,” Waller continued. Can we say with certainty that patients are receiving high-quality cognitive therapy when the clinician's door closes, or that a prescriber understands proper dosing of agonist medication, or knows what to do about the medication decision when the patient is taking other drugs of abuse?
Both Waller and Clark emphasized that a consistency of approach is sorely needed. “Treating addiction like any other disease will increase standardization,” Clark predicted.