In 2011, doctors wrote more than 131 million prescriptions for hydrocodone, making it the most widely prescribed drug in the United States. Along with oxycodone, it is also the most abused. Both opioids have fueled an epidemic of addiction and fatal overdoses that outpace those from heroin and cocaine combined.
The problem is not just that opioid prescriptions for chronic noncancer pain have doubled in the last decade. It is also the drugs' lack of long-term efficacy. Patients need higher doses over time to achieve the same level of pain control, leading to an increased risk of dependence, addiction and overdose and to reduced quality of life, according to Larissa L. Loukianova, M.D., Ph.D., an addiction psychiatrist at Mayo Clinic in Minnesota.
Barbara K. Bruce, Ph.D., L.P., clinical director of Mayo Clinic Comprehensive Pain Rehabilitation Center, adds, "Sixty-five percent of adults admitted into our program have experienced chronic pain for an average of 10 years and are on daily opioids, with an average morphine equivalent of 130 milligrams. Yet despite high doses of these medications, their functioning is poor and their pain levels are very high."
Mayo Clinic has one of the largest adult and pediatric pain rehabilitation programs in the country, treating more than 700 patients a year. It also has one of the most skilled and experienced programs for safe and effective tapering of low- and high-dose opioids. "Our adult pain rehabilitation program has been in operation since 1974. One of the goals has always been to taper narcotics completely over the course of the program," Dr. Bruce says. "But we don't just taper medications, we taper them in the context of many other strategies for pain management, including physical and occupational therapy, stress management and relaxation techniques, biofeedback, and cognitive behavioral therapy."
Most pain center patients enter a three-week, hospital-based outpatient program, though a two-day program also is available. In addition to treating a broad range of pain types, the programs address co-occurring medical and mental health disorders. Dr. Bruce says the primary aim is functional restoration and improved quality of life — "the ability to work, volunteer, be a productive parent and spouse."
Of patients who complete the three-week program:
- 84 percent report better pain control despite discontinuing pain medications
- 93 percent note an increase in aerobic activity
- More than 80 percent report fewer depressive symptoms
Longitudinal data show that the majority of patients continue to experience significant and sustained improvements in pain severity and functioning six months after treatment.
Pediatric pain program
In 2010, Mayo created a pediatric pain rehabilitation program co-led by Tracy E. Harrison, M.D., a pediatric anesthesiologist and pain physician, and Karen E. Weiss, Ph.D., L.P., a pediatric psychologist.
The pediatric and adult programs have similar structures, but the issues and stressors teens face are very different. "By the time children enter our program, they have often been out of school for two or three years, have seen multiple physicians, and are on all kinds of pain medications — about 20 percent on opioids," Dr. Harrison explains. "We taper them off their medications and work with families and educators to get them back into school, into sports, into their lives. We give them hope and a very clear trajectory."