TREAT ADDICTION, DON'T IGNORE CHRONIC PAIN

Facing one of the worst public health crises of recent times, we also encounter a curious dichotomy: that of the need to curb opioid abuse and addiction while also catering to the needs of those with chronic pain who would be unable to function without opioid treatment. Many of the efforts currently proposed by lawmakers may address the former, but only at the expense of the latter. The solution to our conundrum, it seems, may lie in employing risk management strategies and altering our prescribing habits.

The Drug Enforcement Administration (DEA) currently distinguishes between five drug "Schedules," in which Schedule I drugs have the most potential for addiction and abuse, and Schedule V has the least. The most commonly prescribed for pain are Schedule II drugs like morphine, fentanyl, hydrocodone, and oxycodone. Many clinicians are unfamiliar with Schedule III options, such as buprenorphine, which can treat pain effectively, but with less purported abuse, addiction and overdose potential compared to Schedule II products.

Buprenorphine has been adopted as a useful treatment in both specialties of pain and addiction medicine. As a partial agonist, buprenorphine has very high affinity and low intrinsic activity at the mu receptor, unlike the high activity of most Schedule II opioids. Buprenorphine also has uses in treatment for those suffering from addiction, helping to restrict craving for opioids while minimizing the physical effects of withdrawal. On top of this, it has what professionals describe as a "ceiling effect" on respiratory depression caused by other opioids- a common cause of opioid-related overdose death. What this means is that after a certain amount of buprenorphine is taken, the harmful effects on the respiratory system are potentially capped and controlled. With all of these benefits, we must ask ourselves why buprenorphine is so much more difficult to access for those struggling with chronic pain or addiction? The answer is multi-faceted and related to both regulatory and prescription practices.

Despite recognition of the decreased risk of buprenorphine compared to Schedule II opioids, the Centers for Disease Control and Prevention's (CDC) guidelines on the treatment of chronic pain do not distinguish between buprenorphine and more commonly prescribed Schedule II drugs. In fact, the CDC is rather silent on the use of buprenorphine for pain management, and actually recommends that clinicians initiate more potent Schedule II immediate release opioids. In addition, the Food and Drug Administration (FDA) places Schedule III buprenorphine drugs under the same labeling requirements as Schedule II opioids despite lower risks, making it harder for both consumers and healthcare providers to make the distinction.

The problem does not squarely lie in the hands of regulators, however. Insurers also make it more difficult for patients to obtain buprenorphine, whether by offering inadequate coverage for buprenorphine-based products or by requiring patients to try numerous less expensive (though riskier) Schedule II drugs before they will allow patients to obtain buprenorphine. These Schedule II drugs often also require no prior approval before prescription, while buprenorphine may face a lengthy approval process.

The backwards logic of these practices is not lost on doctors. Former CDC Director Thomas Frieden wrote alongside Brandeis University'sAndrew Kolodny in the Journal of the American Medical Association that "It seems illogical that buprenorphine, the one opioid that appears to be safer than commonly prescribed analgesics and heroin, is the only one with such barriers to prescription."

It is time that we, for the sake of both chronic pain patients and those with opioid use disorder alike, call on our policymakers to address this oversight in their regulations and guidelines. We must also make it clear to insurers that though more common Schedule II opioids may be cheaper than buprenorphine, the resulting risks patients face will cost insurers far more in the long-run than if they were to receive buprenorphine from the start. By doing this, we can be one step closer to addressing the problem of how to treat people dealing with chronic pain while limiting the risk of addiction.

Dr. Jeffrey Gudin, M.D., is director of pain management and palliative care at Englewood Hospital and Medical Center.