Doctor discusses role of opioids in treating chronic pain
Dr. Michael Schatman spoke with the Justice about opioid policy, the role of the media in the opioid crisis and misconceptions about opioid prescription.
The Justice spoke with Dr. Michael Schatman, adjunct faculty member at Tufts University Dental and Tufts University Medical School and editor in chief of the Journal of Pain Research, about prescription opioid policy in the United States in an Oct. 29 interview. Schatman responded to the points that Medical Director of Opioid Policy Research at the Heller School for Social Policy and Management Dr. Andrew Kolodny raised in a recent interview with the Justice regarding opioid prescription.
Prescription opioids are a contentious issue in pain patient and medical communities, with one end of the spectrum arguing for more regulation of this type of pain management medication, and the other end arguing that these regulations are harmful. Schatman told the Justice that he places himself in the center of this spectrum, seeing opioids as “the last option for treatment,” but sometimes necessary. Kolodny, on the other hand, argues for stricter regulation of opioid prescription for chronic pain patients, as he explained in his interview with the Justice.
The spectrum of opinions on opioid prescriptions has become increasingly binary over the last decade. Schatman explained that the medical community went from over-prescribing opioids, or being “opiophelic,” to not prescribing the drug enough, or being “opiophobic.” Schatman argued that “Kolodny’s rhetoric, hyperbole, bullying and outright lies, particularly to the media, have had a deleterious impact on pain medicine.”
Schatman co-wrote a 2015 Journal of Pain Research article that discusses the role of the media in the ongoing opioid crisis. The media spends a disproportionate amount of time covering opioid overdoses and deaths but does not “write stories regarding the millions of Americans with chronic pain whose qualities of life are actually enhanced through their appropriate utilization of opioid analgesics,” the article explains.
Schatman said that Kolodny has contributed to this problem by giving hyperbolic interviews for years. “The media didn’t know any better, so they lapped it up,” he explained. While Schatman admitted that he thinks Kolodny is a true believer of his stance on opioids, he noted that “the media has done no favors to society by continuing to go to him” to discuss opioid prescription policy. However, Schatman admitted that “there’s rhetoric and hyperbole on both sides” of the prescription opioid debate.
Schatman explained that much of the available data regarding opioid misuse is misleading, especially when data regarding prescribed and illicit opioid use are conflated. In Massachusetts and New Hampshire, for example, 93-94% of opioid overdoses are due to drugs like illicit fentanyl, heroin and methamphetamines, not prescribed opioids, he said. In a 2019 Journal of Pain Research article, Schatman and his co-writers explained that oversimplifications of the details of the opioid crisis have led to harmful policies. Rather than prohibiting specific drugs across the board, policymakers “should consider prioritizing harm reduction measures such as expanded access to medication-assisted treatment, needle exchange, and supervised injection facilities, and rescheduling naloxone to make it available as a truly over-the-counter drug,” the article explains. Naloxone is a medication designed to rapidly reverse opioid overdose, according to the National Institute on Drug Abuse.
Kolodny explained in his interview that many opioid users experience hyperalgesia, a phenomenon where opioid patients experience an increased tolerance to opioids that coincides with a decreased tolerance to pain. Schatman confirmed that “hyperalgesia is real,” but in his experience working with chronic pain patients, hyperalgesia appears in only 10-15% of pain patients on opioids and is largely dependent on a person’s genetic makeup. He explained that if a patient is demonstrating signs of hyperalgesia, they can be tapered off of that opioid prescription. Schatman said that he has tapered approximately 200 patients off of opioids, and only one patient requested to be put back on.
Concern about increasing opioid tolerance, aside from hyperalgesia, is another point of contention in the medical community. Schatman said that genetics also have an impact on the rate of habituation, which is when the body develops a psychological tolerance to a drug. Some of his patients stay on a steady dosage, he said, while others experience a rapid tolerance increase. According to Schatman, rapid habituation is often caused by a patient being on the wrong type of opioid for their body. “With certain opioids, certain patients are abnormal metabolizers, and they’re either ultra-rapid or ultra-slow,” he explained. “And either way, these patients are more likely to habituate quickly.”
According to Schatman, pharmacogenomics — the study of how someone’s genetics impact their response to different types of medications — is a key part of safe opioid prescription. He explained that this type of research is more common in Europe than in the United States because most U.S. insurance plans do not pay for pharmacogenomical analyses. Schatman also added that most American physicians do not have a sufficient understanding of pharmacogenomics.
Insurance limitations also impact the approach to prescribing opioids in the United States, Schatman said. In 1999, he explained, there were more than 1,000 interdisciplinary pain management programs. These programs included pain physicians, “physical therapists, occupational therapists, psychologists, feedback doctors, vocational counselors, nurses [and] dieticians,” Schatman said. With these programs, patients would learn “pain self-management” and often be able to decrease or eliminate their opioid dosage.
But as insurance covered pain management programs less and less, Schatman explained, “these programs were just shut down by the hospitals in which they were housed, and what the insurance industry said was, ‘Give them opioids. Give them pain medications.’ … It’s really interesting that the demise of interdisciplinary pain management coincided perfectly with the rise of opioid therapy.”
In turn, many chronic pain patients are losing their quality of life, Schatman explained. “Fifty million Americans suffer from chronic pain. Twenty million of them have high chronic pain. Insurance won’t pay for any of the treatment. What do they do?” he asked.
In response to the protest held outside campus to fire Kolodny, Schatman stressed that freedom of speech is a right that academic faculty should have. “He’s expressed his opinions, and he’s twisted some things around,” he said. “But I think it’s his right to speak.”
In an Oct. 19 interview with the Justice, Kolodny stressed that he was not involved in writing the 2016 Centers for Disease Control opioid prescription guidelines. He also acknowledged that while he is not a pain expert, his clinical work is the treatment of opioid addiction. “I have studied and I am an expert in opioid prescribing patterns and trends and the misinformation [spread by pharmaceutical companies] that changed prescribing practices,” he said.