Afterword: Conclusions

Copyright American Psychological Association. Not for further distribution.

The relationship between chronic pain and the use of opioid analgesics is
a long and complicated one. The United States has struggled with opioid-
related issues in a cyclic fashion since the 1800s, vacillating between lax
and limited prescribing practices. Amidst the fallout of the current opioid
crisis, one favorable outcome is an increased interest in nonpharmacological
treatments for pain. While legislators, policymakers, and guideline writers
have indicated that multidisciplinary care addressing the biopsychosocial
factors relevant in pain experiences and outcomes is recommended (Dowell
et al., 2016; Institute of Medicine, 2011; U.S. Department of Health and
Human Services, 2019b; U.S. Department of Veterans Affairs and Department
of Defense, 2017; U.S. Office of the Assistant Secretary for Health, 2016),
many patients and even many health care providers have yet to shift their
biomedically focused mindset. The crux of the issue lies in the long-standing
conceptualization of all pain in acute terms—as a symptom to be cured
rather than as an ongoing condition requiring multifaceted management.
This myopic conceptualization falls short for the millions of Americans
dealing with chronic pain every day. A result of this belief is that many
people possess the false understanding that chronic pain can be eradicated if
only the “right” intervention is found, discovered, shared with them—that a
deus ex machina will somehow save us from this suffering.
This, in part, led to an overreliance on opioids for so many people,
although a variety of other important factors contributed to this perfect
storm. In the late 1990s, consensus statements from prominent pain-focused

https://doi.org/10.1037/0000209-014
Chronic Pain and Opioid Management: Strategies for Integrated Treatment,
by J. L. Murphy and S. Rafie
Copyright © 2021 by the American Psychological Association. All rights reserved.

171
 172  •  Chronic Pain and Opioid Management

professional societies, direct input from patients to treat pain more effec-
tively, and aggressive marketing of a new drug called Oxycontin to primary
care providers (Rummans et al., 2018) all contributed to and culminated
in a dramatic increase in opioid prescribing. Specifically, the annual number
of prescriptions for Oxycontin, a long-acting extended-release medication
intended for individuals with chronic pain, increased from 670,000 to
6.2 million between 1997 and 2002; during that same period, the total
number of opioids prescribed increased by 45 million (Rummans et al., 2018).
This combination suggested that opioids were T-H-E answer for those who
Copyright American Psychological Association. Not for further distribution.

were desperately seeking one. These potent medications were shared more
liberally than they should have been and were used as a unidimensional
panacea for pain. As recently as 2017, a National Survey on Drug Use and
Health indicated that 11.1 million people aged 12 and older self-reported
that they had misused prescription pain relievers in the past year, which is
likely an underestimate (Center for Behavioral Health Statistics and Quality,
2018). Moreover, data indicate that approximately 1 of every 10 people over
12 years old will develop opioid use disorder (OUD), with only about one
fourth of them receiving treatment (Center for Behavioral Health Statistics
and Quality, 2018).
The reality is that while analgesics—preferably those that are prescribed
judiciously and with a thorough risk–benefit analysis—are an important
part of a comprehensive pain treatment plan, they must not be the entire
plan. It is unreasonable to expect that people can achieve optimal functioning
through a single approach. A full range of treatments must be engaged,
including behavioral health strategies that hold an evidence base for treating
both pain and substance use, such as cognitive behavioral therapy (CBT).
Undeniably, there is a significant need for research and clinical guidance for
integrated approaches to pain and opioid use. On a positive note, various
funded trials are in progress (Darnall et al., 2019; Sandhu et al., 2019;
Vowles et al., 2019), and recent research suggests that approaches such as
CBT can help with both pain and opioid management (Garland et al., 2020).
Any information gleaned from emerging research will help practitioners
increase understanding, improve treatment, and provide consistent messaging
to this population.
While we have seen changes in policy regarding increased restrictions
on opioids, we have not seen commensurate increases in the availability
of comprehensive pain management. This discrepancy is both unjust and
unethical to those who suffer from chronic pain and is related to two separate
but potentially related issues. First, guidelines and data suggest that patients
should engage in a variety of treatments that are not currently covered by
 Afterword • 173

insurance and are not broadly available. Reimbursement for comprehensive

pain management to include nonpharmacological options such as behavioral
pain medicine, much of which has more and higher quality evidence than
the medical/pharmacological options, should be covered by payers. This
coverage is needed to adequately address the co-occurring crises involving
pain and opioids. Second, there is an increased need for training and
education in behavioral pain medicine strategies (Darnall et al., 2016) so that
access to evidence-based treatments such as CBT are more widely available.
Funding should be provided to assist states in educating their health care
Copyright American Psychological Association. Not for further distribution.

providers to better assist individuals with pain, including those who are also
using opioids in an attempt to quell their pain. In addition, training across
disciplines should be prioritized so that practitioners in specialties such as
pain medicine have a better understanding of OUD. These conditions do not
exist in silos and should not be treated as such.
The biggest challenge is how to shift the zeitgeist—to move the populace
from pointing fingers outward for someone else to “fix” their health-related
issues and instead encourage individuals to become formidable agents of
change in their own health care. As a society, we must shift the focus
to maximizing overall wellness, which incorporates the many facets of the
whole person and the importance of behavioral choices. When we help arm
individuals with tools to improve their capacity to manage pain and opioids,
they are empowered not just to achieve improved health but to live life
more fully.