‘So much misinformation’: Opioid use in chronic pain informed by persistent myths
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Popular myths continue to influence the way physicians and patients alike think about and engage with chronic pain and the use of opioids, according to a speaker at the 2023 Biologic Therapies Summit.
“Part of what I am trying to do, as we try to reset and begin to look at chronic pain anew, is look at how we were complicit and how we allowed so much misinformation about both opioids and chronic pain to spread,” Haider Warraich, MD, of Brigham and Women’s Hospital, told attendees. “I am going to share a few examples that can illustrate just how we let this happen.”
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The first myth Warraich highlighted was that opioids cause addiction in fewer than 1% of patients who use them.
“The first myth, or lie, whatever you want to call it, is the fact that opioids cause addiction in less than 1% of pain patients,” Warraich said. “This really became the hallmark, the bedrock, of not only education but also the marketing of drugs for people with chronic pain.”
The claim, Warraich said, originated in a research letter that was published in The New England Journal of Medicine in the 1980s.
“If you look at what happened afterward, this paper was cited hundreds and thousands of times in the medical literature, almost always completely affirmationally without any sort of contesting of its conclusions,” Warraich said. “And this was really just the tip of the iceberg.”
The paper is still accessible online but includes a disclaimer regarding the uncritical citations associated with it.
The second myth Warraich counted is the idea that patients who are undertreated for chronic pain may be at risk for developing “pseudo addiction.”
“This originated from a case report — a single case report — of a single 17-year-old boy who had leukemia,” Warraich said. “The authors said that the treatment for someone who was showing behaviors consistent with opioid addiction is in fact giving them more opioids.”
One of the authors of the case report, Warraich stated, went on to work with Purdue Pharma as chief medical officer. No researchers attempted to validate the findings, he added.
The third myth Warraich addressed related to the issue of long-acting opioids and their presumed characteristic of being less addictive than other opioids when used for chronic pain.
“Then there is this other concept, the fact that long-acting opioids, as opposed to short-acting opioids, are less addictive and more suitable for chronic pain,” Warraich said. “This was actually from the FDA label for OxyContin (oxycodone, Purdue Pharma) itself.
“This is a very powerful statement, and the FDA label, for those who are not aware, is a very, very powerful document because that sets the standard and basis for how you can advertise and market these drugs,” he added.
However, there was no evidence that the claim was pitched by Purdue Pharma, Warraich said, adding that the implication is that the FDA added the claim “of its own initiative.”
The fourth myth that Warraich discussed is that opioids are effective for use in patients with chronic pain.
“We know today that there is in fact no evidence to support that statement,” Warraich said. “The fact is that opioids are probably the best option we have available for acute pain, but chronic pain is a totally different beast.”
The final myth Warraich addressed was the racist, discredited — and yet all too pervasive — idea that Black patients have a higher pain threshold than other patients.
“The origin of this belief comes from this physician, who is pretty despicable,” Warraich said. “His name was Samuel Cartwright.”
Cartwright made up medical conditions and posited that Black patients were insensitive to pain, and therefore could not feel the violence he was inflicting upon them, according to Warraich.
“In a very recent survey, they surveyed medical students and residents, and they asked them a lot of questions, one of which was whether they believed Black peoples’ skin was thicker than white peoples’,” Warraich said. “They found that almost a third of medical students and residents had this belief, and that people with these beliefs were also less likely to provide pain relief to their Black patients.”
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Warraich H. The nature of pain. Presented at: Biologic Therapies Summit X; May 11-13, 2023 (hybrid meeting).
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