• CDC Guideline on Prescribing Opioids for Chronic Pain (2016)

• CDC’s: press release on how guideline is being misapplied and accompanying article by Guideline authors, New England Journal of Medicine 

• CDC Guideline Opioid Workgroup.  CDC’s announcement of workgroup for revising 2016 Opioid Prescribing Guideline.

• Canadian Opioid Prescribing Guideline (2017)

• VA/DOD Clinical Practice Guideline on opioid prescribing 

• FDA Warning on Dangers of Tapering

• HHS Guideline on Tapering

• Hoffmann et al.  found that false clinician beliefs about biological differences between blacks and whites were associated with the perception that black people feel less pain resulting in inadequate treatment.

• Sabin and Greenwald found that implicit racial biases in pediatricians lead to less pain medication for black teens after surgery. 

• Meghani and Gallagher meta-analysis of 20 years of studies) found that Black patients are less likely to receive any pain medication.

• Power-Hays and McGann discuss the damaging intersection of racism and sickle cell disease.

• Lee et al. in a meta-analysis found that Black patients are 40% less likely and Hispanic patients are 25% less likely than whites to receive medication for acute pain in the Emergency Room.

• Yet, a recent study using FMRI brain imaging by Reynolds et al. found that Black patients likely experience greater pain than white patients.

• And Brown et al. showed that some 4 Million Americans experience chronic pain due in part to discrimination.   

• Taylor discusses how inequities in healthcare generally also disproportionately affect people of color.

• Pain is the chief cause of disability worldwide, according to the global burden of disease studies.

• Low back pain is a major cause of disability according to global burden of disease studies. 

• Pain is a top cause of YLD (years lived with disability) (expressed in terms of musculoskeletal disorders like low back and neck pain, osteoarthritis, rheumatoid arthritis, gout and others) according to the Institute for Health Metrics and Evaluation (IHME).

• Individuals with disabilities face conscious and unconscious biases in healthcare; these biases intensify for people with disabilities of color, and have implications for pain management.

• Individuals with disabilities still experience barriers related to communication, physical access and access to medical equipment and these barriers may affect pain management.

• Individuals with intellectual or developmental disabilities also face barriers in healthcare access and outcomes that have implications for the management of their pain.

• Veterans experience chronic pain at rates higher than those of the general population and are about 40% more likely to have severe pain according to the VA’s Health Services and Research Development.

• Nahin shows greater severity of pain in Veterans as compared with the general population. 

•  Olenick et al. reports that pain is one of the chief health complaints of Veterans. 

• Friedrichsdorg & Goubert found that pain prevention and treatment in children is inadequate.

• Pain is rising among younger Americans as compared with the previous generations according to the National Institutes of Health. 

•  Patel et al. found that bothersome pain afflicts 18.8 Million older adults in the US.

• Molton and Terrill report that more than 2/3 of older Americans suffer multiple chronic conditions; an estimated 60-75% of those over 65 report persistent pain; and that epidemiology suggests pain increases with age. 

• Princeton/USC study suggests that Americans are experiencing increasing pain in middle age.

Tapering Studies & Studies on Patient Abandonment:

• Between 8 and 13 Million Americans currently take opioids to manage pain. 

• Anyone who has taken opioids long-term is likely to develop physical dependence, requiring that opioids be tapered slowly to avoid side effects.

Several studies over the last few years show dangers of opioid dose tapering or discontinuation in people currently taking opioids:

• Mark & Parish found that of Medicaid patients who had been on high dosages for more than 90 days, the average time to discontinuation of opioids was 24 hours, with almost half resulting in hospitalization or ER visit.

• Glanz et al., found a three-fold increase of overdose death, just from destabilizing dosage.

• James et al., found that tapering resulted in increased mortality risk in primary care settings. 

• Fenton et al., found that tapering was happening too abruptly and disproportionately to women and people of color.

• Oliva et al., found a higher risk of death from overdose or suicide in Veterans who experienced opioid tapering.

Other studies show that people who use opioids to manage pain have challenges finding healthcare at all:

• Perez et al., found that opioid tapering is associated with later termination of care relationships between providers and patients. 

• Lagisetty et al., found that approximately 40% of primary care physicians are unwilling to take on a new patient who uses opioids to manage pain.

• Wohlgemuth et al., found that 81% of physicians are reluctant to see a patient who uses opioids to manage pain.

Addiction and overdose risks among pain patients: 

• There is a critical difference between addiction to and physiological dependence on a medication. Addiction is compulsive use that continues despite harmful consequences. Dependence lacks the destructive behavioral component of addiction; people who appropriately use medication typically have helpful consequences.

• Most people who misuse prescription opioids did not get them directly from a doctor but rather bought, stole or borrowed medication that was prescribed to others. 

• The risk of addiction to people who are prescribed opioids varies considerably according to risk factors that should be screened for in prescribing but generally the risk varies from .06% to less than 8%.

• The risk of overdose death in patients prescribed opioids for pain is also relatively low.  One study of 2.2 Million people found the risk of death at less than .022%.

• Most overdose deaths involve multiple drugs--legal and illegal--used in combination; one study found that the average number of substances in the system of someone who died of overdose was 6.

• Opioid prescribing in the US has fallen since 2012, while overdose deaths have risen exponentially since that time largely driven by heroin, illegal fentanyl and its potent analogs and stimulants.  

On pain’s prevalence and social costs:

• 100 Million Americans have some form of chronic pain; chronic pain affects more than heart disease, diabetes, cancer and stroke combined.

• 50 Million Americans have pain every day or nearly every day of their lives. 

• 40 Million Americans report pain that is severe.

• Nearly 20 Million Americans report pain that regularly prevents them from engaging in basic work and life activities. 

• Pain is rising among younger and middle aged Americans

• Pain is the chief cause of long-term disability in the US and worldwide. 

• People in pain are 4 x more likely to suffer from depression and anxiety.

• People in pain experience higher suicidality and higher rates of suicide. 

• The US spends upwards of $635 billion per year (in 2011 dollars).

On pain education:

• On average medical students get only 9 hours of training on pain assessment and treatment; 96 % of US and 80% of UK programs entirely lack mandatory pain education.

• Only 4 US medical schools had a single required course on pain. 

• On pain generally and new FMRI brain imaging of pain, Twilley, Neuroscience of Pain, New Yorker

• On pain policy, Goldberg, Toward Fair and Humane Pain Policy, Hastings Center Report

• On pain stigma, Goldberg, Pain, Objectivity and History: Understanding Pain Stigma

• On why pain education, research and treatment need to be transformed and how to do it, Darnall, Reducing the Global Burden of Chronic Pain, Global Solutions Journal.

• On how to transform research on pain, Darnall, To Treat Pain Study People in all their Complexity, Nature

• On the need to add pain to the curriculum in psychology programs, see Darnall et al., Pain Psychology: A Global Needs Assessment and National Call to Action, Pain Medicine.