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JAMA Forum
April 21, 2022

The False Dichotomy of Pain and Opioid Use Disorder

Author Affiliations
  • 1VA Boston Healthcare System, Boston, Massachusetts
  • 2Boston College Connell School of Nursing, Boston, Massachusetts
  • 3Center for Health Policy and Media Engagement, George Washington University School of Nursing, Washington, DC
  • 4Catskills Addiction Coalition, Arkville, New York
JAMA Health Forum. 2022;3(4):e221406. doi:10.1001/jamahealthforum.2022.1406

On March 3, 2022, the Sackler family agreed to a settlement of up to $6 billion on behalf of Purdue Pharma in response to litigation that alleged that the company promoted OxyContin—an early driver of the opioid crisis—while knowing it was resulting in significant opioid harms. But it will take more than money to ensure that people suffering from pain and opioid use disorder (OUD) receive appropriate care. A new paradigm to undergird US policies and practices is needed, one that aligns the need for safe and equitable opioid access for people with both pain and OUD.

To see the flaws in the current US system, one needs to look no further than cancer. More than half of patients with cancer experience moderate to severe pain and many require opioid management even after the completion of cancer therapies.1 Although the opioid-centric approach to cancer pain management and the exemption of cancer pain from such national pain guidelines as those from the US Centers for Disease Control and Prevention seem to assume that people with cancer are not at risk for OUD and other opioid harms, people with cancer have a higher prevalence of substance use disorders compared with people without cancer.2 Despite this risk, most cancer centers do not offer addiction services and less than 15% of palliative care clinicians possess the required X waiver to prescribe buprenorphine for OUD.3

People with pain and OUD have limited care options because of existing policies that isolate addiction treatment from the rest of health care. Methadone and buprenorphine are opioid analgesics approved by the US Food and Drug Administration and are gold standard medications for treating OUD, but divergent regulations make them challenging to access for either indication and nearly impossible for a dual indication of pain and OUD.4,5 Any licensed clinician certified by the Drug Enforcement Agency can prescribe opioids for pain, but when treating OUD, methadone is limited to federally regulated opioid treatment programs and buprenorphine is limited to clinicians who possess the X waiver.

Failed Policies

Existing policies force clinicians to assign people with pain to one group and people with OUD to another, thereby driving value-laden judgments about the legitimacy of opioids for a given person and condition—judgments associated with racial, ethnic, and socioeconomic inequities. Racial disparities in access to pain management and opioids are well documented. For example, buprenorphine is less likely to be available through health care facilities in Black communities than in White communities. Methadone, sometimes referred to as “liquid handcuffs,” is the dominant medication prescribed for OUD disorder in Black patients and can only be dispensed in federally licensed opioid treatment programs.6

The assessment and treatment of pain and OUD, including the regulation of buprenorphine and methadone, is based on a false dichotomy. Approximately 10% of individuals prescribed opioids for pain will develop an OUD, and about 25% will manifest concerning behaviors that may indicate a “subclinical” OUD. Buprenorphine and methadone are important tools in cancer pain management and they can significantly decrease mortality and improve quality of life for people with OUD.4 In palliative care, methadone and buprenorphine are regularly used as analgesics; however, OUD treatment without an X waiver or outside a methadone treatment program is illegal.3 The lack of integration of OUD in specialties such as oncology has also led to therapeutic nihilism, and the view that people with OUD do not get better perpetuates stigma rather than emphasizing the barriers to obtaining life-saving treatment.

Currently, there are limited options for people with OUD who develop cancer or other conditions associated with painful sequelae despite undertreated pain and serious illness being powerful triggers for a return to nonmedical opioid use.4 If a patient with OUD is treated with methadone then develops cancer, it is difficult to address pain with methadone as a dual treatment without violating federal regulations or state-based policies. Sometimes clinicians in cancer care circumvent the system and take over methadone prescribing, but this a precarious situation that violates federal policy and has few safeguards to optimize patient safety.5

Fear and scrutiny around opioid prescribing have dire consequences for people with opioids prescribed for pain, with forced opioid tapers resulting in increased risk of opioid overdose and reduced access to primary care. Even among people with cancer, a condition for which opioid use is consistent with guidelines, more than half of patients experience stigma associated with their opioid prescriptions, including strained relationships with clinicians and difficulty filling an opioid prescription.

Policy Solutions

The X waiver is a barrier to accessing appropriate treatment of both pain and OUD. Since 2021, buprenorphine guidelines from the US Department of Health and Human Services have allowed clinicians to treat 30 patients with buprenorphine for OUD without the additional education requirement. A better solution is to eliminate the X waiver altogether and have all Drug Enforcement Agency–certified clinicians become familiar with buprenorphine prescribing.7

In 2019, a report by the National Academies of Science, Engineering, and Medicine concluded that current regulations around methadone and buprenorphine are not empirically based and impose substantial restrictions on life-saving medications. A recent workshop to inform the work of the Office of National Drug Control Policy included evidence obtained during the SARS-CoV-2 pandemic, when flexible methadone policies permitted take-home doses. This change did not increase overdose rates, prompting advocacy for methadone programs to permanently decrease attendance requirements and in-person dosing. Flexibility in where methadone can be dispensed is needed. Concurrent care models to deliver medication for OUD within cancer centers would decrease barriers for people with cancer and provide greater opportunity for flexible dosing for cancer-related pain and OUD, and pharmacy-based dispensing, which has been widely adopted in other countries, could also be helpful. Methadone clinics are an anachronism of a 50-year-old federal policy for which innovation is sorely needed.

Concurrent management of pain and OUD can be reimagined with the increased use of telehealth, with early evidence suggesting equivalent care. Although less than 1% of OUD care was delivered via telehealth before the SARS-CoV-2 pandemic, since March 2020, clinicians have been allowed to initiate and manage buprenorphine over the phone. Likewise, telehealth could significantly improve interdisciplinary collaboration on multimodal approaches for addressing the high rates of opioid prescribing, substance use, and chronic pain associated with cancer, as the Veterans Administration health care system has done with noncancer pain.

More research is needed on how OUD and pain conditions interact as well as best practices in prescribing for both. As states and the federal government gain access to funding from opioid settlements, patients and clinicians alike could benefit from a national research agenda that can inform how to transform US mental and behavioral health services.

Discomfort and stigma in treating OUD and pain require shifting societal attitudes and disseminating evidence. The opioid settlement funding should build on existing public education campaigns to counter stigma and highlight the voices of people with lived experience of pain and OUD. These campaigns need to reach policy makers and clinicians as well.

All communities and patients should have access to clinicians with the authority to prescribe the appropriate medication for the treatment of OUD, pain, or both conditions. But it will require policy makers to develop more flexible policies that address the needs of patients with pain and OUD and clinicians to implement these policies in ways that end OUD-associated stigma.

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Article Information

Published: April 21, 2022. doi:10.1001/jamahealthforum.2022.1406

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Jones KF et al. JAMA Health Forum.

Corresponding Author: Diana J. Mason, PhD, RN, Center for Health Policy and Media Engagement, George Washington University School of Nursing, 1919 Pennsylvania Ave NW, Ste 500, Washington, DC 20006 (djmasonrn@gmail.com).

Conflict of Interest Disclosures: Ms Fitzgerald Jones reported receiving grants from National Institute of Nursing Research (Ruth L. Kirschstein National Service Award F31NR019929-01) and receiving grants as a Jonas Mental Health Scholar (2020-2021). Dr Mason reported being the unpaid chairperson of the Catskills Addiction Coalition, which is the recipient of a subcontract from REACH Medical on a federal Rural Community Opioid Response Program grant.

Jones  KF, Fu  MR, Merlin  JS,  et al.  Exploring factors associated with long-term opioid therapy in cancer survivors: an integrative review.   J Pain Symptom Manage. 2021;61(2):395-415. doi:10.1016/j.jpainsymman.2020.08.015PubMedGoogle ScholarCrossref
Jones  KF, Merlin  JS.  Approaches to opioid prescribing in cancer survivors: lessons learned from the general literature.   Cancer. 2022;128(3):449-455. doi:10.1002/cncr.33961PubMedGoogle ScholarCrossref
Merlin  JS, Patel  K, Thompson  N,  et al.  Managing chronic pain in cancer survivors prescribed long-term opioid therapy: a national survey of ambulatory palliative care providers.   J Pain Symptom Manage. 2019;57(1):20-27. doi:10.1016/j.jpainsymman.2018.10.493PubMedGoogle ScholarCrossref
Wakeman  SE, Larochelle  MR, Ameli  O,  et al.  Comparative effectiveness of different treatment pathways for opioid use disorder.   JAMA Netw Open. 2020;3(2):e1920622. doi:10.1001/jamanetworkopen.2019.20622PubMedGoogle ScholarCrossref
Merlin  JS, Khodyakov  D, Arnold  R,  et al.  Expert panel consensus on management of advanced cancer–related pain in individuals with opioid use disorder.   JAMA Netw Open. 2021;4(12):e2139968. doi:10.1001/jamanetworkopen.2021.39968PubMedGoogle ScholarCrossref
Jordan  A, Mathis  M, Haeny  A, Funaro  M, Paltin  D, Ransome  Y.  An evaluation of opioid use in black communities: a rapid review of the literature.   Harv Rev Psychiatry. 2021;29(2):108-130. doi:10.1097/HRP.0000000000000285PubMedGoogle ScholarCrossref
Weimer  MB, Wakeman  SE, Saitz  R.  Removing one barrier to opioid use disorder treatment: is it enough?   JAMA. 2021;325(12):1147-1148. doi:10.1001/jama.2021.0958PubMedGoogle ScholarCrossref
5 Comments for this article
Bold and Correctly Stated
Paul Buehrens, MD, FAAFP | Retired family physician
Thanks for publishing this. It is clear and ought to be quite obvious, although clearly it is not. The regulation of methadone for OUD only is absurd. With a bit of knowledge and a DEA license it has its place in treatment of chronic pain. Chronic pain is avoided like the plague by almost all the specialty colleagues I have ever worked with outside of the rare doctor who will engage. These have been physiatrist, psychiatrist, and addiction specialists. Otherwise it has always fallen on primary care. Management of chronic pain patients is significantly time-consuming and more difficult than managing hypertension or diabetes. Although we manage chronic pain in high volumes, I have not even met a primary care doctor except as above who wanted to even have a certificate for suboxone, for fear of attracting yet more patients with chronic pain. The author is right on also in pointing out that there is, and again, it should be utterly obvious, overlap between those with OUD and chronic pain, and these are a substantial proportion of the chronic pain patients. FFS reimbursement and arcane difficult coding and billing are substantial barriers to quality care in this and a myriad of other areas.
The Need for a Different Approach
Michael Connelly, MD | Retired Pain Specialist
The false dichotomy would be better stated as deciding to either prescribe opioids or not treat chronic pain. We all recognize that understanding and treating chronic pain is very demanding, and not adequately supported in our current FFS structure. The result has been excessive reliance on injections, surgery, and opioids. The overlap of chronic pain and OUD is a consequence of prescribing opioids for chronic pain without evidence of safety and efficacy. The pain continues and the patient develops a consequence of treatment that may be well intended but is misguided. The way forward is learning more about the neurophysiology of pain, including the role of the how people respond from a physical, social, and psychological perspective, and less reliance on injections, surgery and opioids.
Two Distinct Yet Connected Issues - Pain Prevention and Treatment and Opioid Use Disorder
Richard Ricciardi, PhD, CRNP | George Washington University
Thank you for calling out the wide gaps in 1) pain management and 2) treatment of addiction; two distinct yet undoubtedly connected issues. Further, gaps in knowledge and treatment exist in not only treating chronic pain but also in mitigating or blocking the transition of acute pain to chronic pain.

Due to the varying etiologies of chronic pain and the goals for treating it, it is unlikely that that any one treatment (such as prescribing opioids) will be adequate in controlling pain and maintaining the individual’s goals and quality of life. Evidence supports that chronic pain is
best managed using a multimodal patient-centered approach. However, access to multimodal pain management services is limited or nonexistent in many areas of the US. Multimodal approaches include the use of noninvasive and nonpharmacological pain treatment as described in the National Pain Strategy. Moreover, more information on medication treatments for opioid use disorders are provided by SAMHSA

As you mention in the Forum article, cancer pain is often seen in a special category and is managed according to the individual’s specific needs and the type of cancer - as differing types of cancer necessitate different forms of treatment and pain management. Further, cancer pain is often managed by the cancer patient and their oncology team – versus a primary care provider.

Moving forward there are many opportunities to improve antiquated state and federal policies to reduce barriers and increase access to multimodal pain and addiction treatment. One immediate action is to eliminate the X-waiver, and restrictions on prescribing buprenorphine and other opiate replacement therapy drugs in primary care settings. Further, there is a need to change the current reimbursement structure to incentivize primary care providers and practices to be appropriately reimbursed for the complex care of individuals with chronic pain, addiction treatment and services. and the treatment the patient’s associated comorbidities. The reimbursement policies should include incentivizing models of care that increase access to pain and addiction care to underserved and geographically challenged populations – and support the integration of behavioral/mental health in primary care. Moreover, there is a need to increase funding to train the primary care workforce on evidence-based care in pain management and addiction treatment and services.

Finally, I acknowledge that there is national call to action to prevent and treat opioid use disorder and eliminate overdose deaths. I would like to add an additional call to action to improve policies that address the prevention and treatment of alcohol use disorder – an often overlooked and deadly epidemic.
Yes But...
Justin Moeling, LICSW | Opioid Treatment Program, Director
This is a great article and I feel it hits on so many important topics. The silos within healthcare are barriers to truly exceptional care. It would be nice to have a world where medicine, behavioral medicine, addiction psychiatry, psychiatry, mental health, SUD treatment, and MAT for opioid use disorders all fell under the same integrated umbrella. With an aging patient population we need to make it easier for patients with OUD to get their methadone when they are in rehab or in a nursing facility care. It should be easier to start patients on methadone in acute care vs waiting until outpatient. Anything we do to improve access to treatment is life-saving. This is where my disagreement starts. The Federal Guidelines for Opioid Treatment Programs would definitely benefit from being overhauled and updated. The politics that are wrapped around MAT for OUD are overkill and more than most other medications. Yes, we have had the benefit from the increase in discretion during the COVID-19 pandemic and yes, we have seem minimal consequences in spite of the perception of increased risk. Having done this for 15 years now, it has been nerve-wracking to provide methadone take-home medication for folks still actively using. One of the biggest positives has been the ability to improve our attempt to be patient-centered in our work.

I think it is unfair to describe methadone clinics as anachronistic. There is more to methadone treatment then just the medication. The focus should be on revising policy. Not mentioned in the original post is the tremendous benefits of methadone clinic attendance, often daily interactions with healthcare professionals, daily brief assessment for mental status and possible health concerns, and frequent drug screens. Providing methadone in a purely physical medicine setting leaves out the psychosocial and psychological care that is so valuable. We have patients actively using hard drugs that do not have pain issues. These patients are often better served in a more specialized environment. The client or patient who is homeless and a chronic and severe user of heroin/fentanyl certainly presents differently than the pain patient that seems to have been prematurely cut off from pain medication and still seeking relief. Both of these patient deserve the best care and respect we can give. The methadone clinic can provide that. Maybe we co-locate methadone treatment programing with general mental health and primary care? Maybe we have MAT clinic vs separating buprenorphine and naltrexone from methadone? My understanding from my own reading is that prior to OxyContin more caregivers reserved opioids for the pain associated with chronically ill and palliative/hospice patients. Maybe we should move further in that direction but with more discretion permitted for the caregivers to better take care of their patients.
In Latin America and Low and Middle Income Countries, the Missing Element is Education
Jairo Moyano, MD, PhD | University Hospital Fundación Santa Fe de Bogotá
The article describes how the opioid epidemic in the United States led to the implementation of specific regulations on the use of opioids (Opioid Prescribing Guideline by the CDC), which unintentionally resulted in limitations for timely access to opioids in patient groups that legitimately need to use these medications.
On the contrary, in Colombia and many Latin-American countries, the clinician does not have to formally classify the patient into the patients with pain group or the inappropriate opioid use group in order to issue a prescription. Although the false dichotomy between the treatment of pain with opioids and opioid
abuse is mainly observed in the United States and other developed countries, inadequate treatment of pain also occurs in low and middle-income countries. This situation is worsened by restrictive policies on opioid access, the fact that health professionals do not receive proper education regarding adequate use of opioids, and the social stigma of being illicit drug-producing countries.

Undergraduate and postgraduate health sciences programs offered by universities in Colombia and most Latin American countries do not include subjects on pain treatment or opioid abuse, which causes an evident knowledge deficit during professional practice. Therefore, clinically valid prescriptions of opioid medications can be denied or, even worse, opioids can be prescribed without an appropriate indication. In the absence of proper education in undergraduate health sciences programs, the pharmaceutical industry provides health professionals with education on pain treatment and use of opioids.

In addition, in Colombia and other Latin American countries, patients with opioid use disorder (OUD) might be exposed to a greater social stigma from society when receiving analgesic treatment, mainly for two reasons: first, due to restricted access to the health system and, second, the fact that there is little social support for the prescription of opioids in these patients.

Thus, it is necessary to overcome the stigma that haunts patients with OUD and chronic pain. Accurately, Jones & Mason (1) state that opioid abuse can be a clinically relevant problem in patients with oncologic pain. In Latin American countries, in middle and low-income countries, there are virtually no representative statistics on the prevalence of OUD in cancer patients.

Furthermore, in countries like Colombia, there is no restriction on the use of methadone or buprenorphine for the treatment of OUD in patients with cancer pain, consequently, the sociodemographic and cultural environment of the patient is partially responsible for the limited use of these medications. In those medical indications.

Finally, in these scenarios and taking into account what the authors have reported, telemedicine represents an essential educational tool for professional training and mentoring, even in low- and middle-income countries

Jairo R. Moyano Acevedo, MD, Phd
Maria F. Santoyo Barco, MD