Opioid prescribing is a surrogate for inadequate pain management resources

Like hypertension, pain is a symptom of underlying disease. If physicians treat hypertension solely with medication, they are doing a disservice to patients. Addressing diet, exercise, sleep and stress actually address the underlying disease process of hypertension, which is endothelial vascular dysfunction related to inflammation, oxidation and immune activation.1

Likewise, when we prescribe opioids for non-cancer chronic pain, we are treating a symptom, not the underlying disease. People with chronic pain do not have opioid deficiency syndrome. Chronic pain syndromes now are thought to be due to underlying microglial cell activation. 2,3 There is also data in animal models that indicate microglial activation arises from systemic peripheral inflammation.4 Inflammation, as a source of chronic non-cancer pain is not unreasonable when you consider that the major causes of mortality - heart disease and cancer are linked to inflammation.5,6

I propose that more efforts should be made in addressing the root cause for the inflammation. Are patients optimizing their diet? We know high sugar and B12 deficiency leads to neuropathy. Low vitamin D has been associated with multiple sclerosis. Are patients exercising? Moderate exercise has been shown to decrease markers for inflammation - CRP, IL-6 and TNF-alpha. 7,8 Are patients getting proper sleep? Inadequate duration of sleep has been directly correlated to increased inflammatory markers - hscrp, IL-6, and TNF-alpha. 9 Are we advising patients to de-stress their lifestyles or advising them how handle that stress with stress reduction techniques like heart-rate variability (HRV) biofeedback? Mediated by vagal parasympathetic reflex stimulation, HRV has been shown to decrease CRP in hypertensive patients treated with HRV biofeedback. 10

Pharmaceutical-wise, low-dose naltrexone (LDN) has evidence as a novel anti-inflammatory agent in the central nervous system, via action on microglial cells; and has been shown helpful in the treatment of pain for fibromyalgia, multiple sclerosis, Crohn's disease and complex regional pain syndrome. 11

1 Houston, Mark. World J Cardiol. 2014 Feb 26; 6(2): 38-66. 2 Gosselin, Romain-Daniel. Neuroscientist. 2010 Oct; 16(5): 519-531. 3 Hulseboch, CE. Exp Neurol. 2008 Nov;214(1):6-9. 4 Hoogland, IC. J Neuroinflammation. 2015 Jun 6;12:114. 5 Black, PH. J Psychosom Res. 2002 Jan;52(1):1-23 6 Schacter, E. et.al. Oncology. 2002 Feb;16(2):217-26, 229; discussion 230 -2. 7 Ford, ES. Epidemiology. 2002 Sep;13(5):561-8. 8 Ambarish V. et.al. Indian J Physiol Pharmacol. 2012 Jan-Mar;56(1):7-14. 9 Patel SR, et.al. Sleep duration and biomarkers of inflammation. Sleep. 2009;32:200. 10 Nolan RP, et.al. J Intern Med. 2012 Aug; 272(2):161-9. 11 Younger, Jarred. et.al. Clin Rheumatol. 2014; 33(4): 451-459.

Conflict of Interest:

None declared