When Dr. Roger Fillingim was going through medical training in the late 1980s, opioids weren't commonly prescribed to chronic pain patients.
In fact, doctors made it their priority to get a patient off opioids. They'd use something Fillingim calls a "pain cocktail." The key ingredient was morphine.
"That was then given to them in liquid form in Kool-Aid," said Fillingim, who now runs the University of Florida's pain research center, "and then slowly reduced over a period of the first week or two."
Doctors would fill the void with everything from physical therapy to meditation. Within a month, patients ideally would be able to deal with their pain without relying on opioid painkillers.
The United States once had a flourishing network of what's called multidisciplinary pain treatment programs, which taught patients to manage their own chronic pain using a variety of treatments. But in the 1990s, just as opioid painkillers became more widely prescribed for chronic pain, many of these programs began closing.
As the opioid epidemic continues to claim tens of thousands of lives each year, prescribers are adopting new guidelines to restrict the use of opioids for chronic pain. And there are worries that there aren't enough pain rehabilitation programs to treat all these additional patients with treatment that can be both costly and time-consuming.
"The question is: What do we now?" Fillingim said. "If we have increasingly provided opioids and other medications for patients, and now we're taking away opioids, which had become one of the mainstays of pain treatment, what are we going to replace it with?"
Treating the 'whole person'
As soldiers returned from World War II with terrible wounds, treatment for pain emerged as a medical discipline. Doctors started to see pain as a complex phenomenon that involves both physical and psychological factors, and which requires the treatment of the "whole person," said Marcia Meldrum, a professor at the University of California, Los Angeles.
By the 1970s, Meldrum said, physicians started to call themselves pain doctors. And clinics, many supported by universities, popped up to offer this multidisciplinary approach to chronic pain. The treatment may take weeks to go through, and it often was not accessible to people without money.
"All this multidisciplinary care takes a while," Meldrum said. "It involves multiple specialists, and most insurance companies will not support this type of thing for any period of time."
Meldrum's research found that in recent decades, the number of multidisciplinary pain clinics declined dramatically. Between 1998 and 2004, as opioid prescribing for chronic pain conditions was booming, the number of pain programs accredited by the Commission on Accreditation of Rehabilitation Facilities in the U.S. dropped from 200 to 125, according to Meldrum's research.
There were larger changes going on in the medical system that likely contributed to this decline. But the new consensus that opioids could successfully treat chronic pain also was a factor.
"Opioids are easy," Meldrum said. "You give a patient their pill and their pain goes away."
From 1991 to 2011, the number of individual opioid painkiller prescriptions more than tripled, according to the National Institute on Drug Abuse. But by the late 2000s, the impact of prescribing opioids in such large numbers was becoming apparent.
"It was clear that OxyContin had become an addictive drug, people were using it in overly large doses, they were selling it on the street," Meldrum said. "There were pill mills across the country where people could walk in and get drugs in quantity."
And people were dying of overdoses. About 40,000 Americans now die each year of opioid overdoses, and many of those deaths are attributed to prescription painkillers.
The crisis has spurred some officials to act. The Centers for Disease Control and Prevention issued guidelines in 2017 that recommended against prescribing opioids for chronic pain. And states, including Minnesota last month, have followed suit. Both sets of guidelines, and other restrictions on opioid prescribing, are based on research that shows that opioids are not effective long-term treatments for many chronic pain patients, especially when considering the dangers of overdose or addiction disorders.
Many chronic pain patients who rely on opioids argue that they're losing access to opioids, which they see as the only form of treatment.
Meldrum says many of the multidisciplinary pain clinics haven't returned to fill the void, especially outside of major cities. But many services they offered can be found elsewhere.
"For the chronic pain patient, the treatments are available still, it's just that they have to spend time searching them out," Meldrum said. "Not surprisingly they find that frustrating."
There are signs that the medical industry is starting to shift back to a broader approach to chronic pain. It's kind of "Back to the Future," said Dr. Murray McAllister of Courage Kenny Rehabilitation Institute, who points to recently opened chronic pain programs in the state at Essentia Health in northern Minnesota and at the Minneapolis Veterans Administration.
"People are recognizing that pain programs have historically been very successful and effective," McAllister said. "We've got a lot of scientific research backing it up."
Insurance companies and government agencies are more open to reimbursing for chronic pain rehabilitation. In 2017, the Minnesota Legislature passed a bill allowing Medical Assistance to pay for the programs. Courage Kenny has been able to come to agreements with most major insurers, which McAllister says may be cheaper in the long-run.
"What we're doing essentially is helping people to self-manage their pain, so they're not going back to getting monthly prescriptions of opioids, or they're not getting repetitive steroid injections, or they're not getting spine surgeries anymore," McAllister said. "They've come to a place where they know what to do and they're managing their pain well, and they're kind of moving on with the rest of their lives."
Part of what needs to happen, said McAllister, is that patients and physicians need to start thinking differently about pain and injuries. The instinct when someone hurts their back is to stay home and rest, but he said research has shown staying active is more effective.
"Our societal understanding of something like back pain hasn't kept up with what science tells us it is and what science tells us is most effective," McAllister said. "What that really is going to require is a whole paradigm shift."
Doctors should be careful not to do damage to those who are already on opioids to treat chronic pain, said Dr. Roger Fillingim. The idea of using opioids only as a last resort is not new, but it makes sense that other therapies that are less likely to cause harm are being emphasized again.
The industry and chronic pain patients may be facing less of a cliff as prescribers cut back on opioids, Fillingim said, and more of a "slowly developing valley that we can come out of on the other side."