Gavin: Pain Acceptance: A Path Forward?

Thursday, January 12, 2017 | 0

The world apparently needs more opioids, so the Food and Drug Administration approved another one Monday.

Michael Gavin

Egalet Corp.'s long-acting morphine formulation, Arymo ER, will hit the market here in the U.S. before the close of the first quarter.

Interesting side note for those interested in the economic value of abuse-deterrence: Egalet stock initially shot up 27% on the approval news. But when it became clear the Arymo label would include abuse-deterrence language for dissolution and injection, but not for snorting or chewing it (because another abuse-deterrent opioid has rights to exclusivity for the particular claim), the stock dropped 16% Monday and another 20% Tuesday morning.  

By my calculations, that drop erased about $70 million in equity value. And according to Yahoo Finance, 58% of the share are held by "insiders" (aka company executives), and one officer, Egalet CEO Robert Radie, holds nearly half of those insider shares. So he's $20 million poorer this morning because he can't claim his new drug cannot be snorted or chewed. If the mix of health care and high finance is a little nauseating to you, you're not alone. 

In other pain management news, there's a really interesting study in this month's Journal of Pain Research regarding the relationship between "pain acceptance" and outcomes measures such as disability, mental health and quality of life. The study also relates this concept of "pain acceptance" to behaviors such as "pain catastrophizing," a phenomenon wherein a person "experiences exaggerated worrying and overestimation of the probability of unpleasant outcomes in response to pain." Notably, the study looks exclusively at a workers' compensation population. 

Not surprisingly, higher "pain acceptance" scores were strongly correlated with less disability, and greater mental and physical health.

"Pain catastrophizing" appeared to have the opposite effect: increased disability and poorer perceived health. If you're wondering why you're hearing so much these days about cognitive behavioral therapy, this is why. 

The study caused me to contemplate the broader picture of where we stand on the issues of chronic pain and opioid use. We get lost in the statistics sometimes and fail to see the forest for the trees. Here's the real bottom line: The last quarter century has seen both an explosion in chronic pain and an explosion in opioid use. The latter does not appear to be mitigating the former. At all. 

From another (highly clinical/technical) study that also crossed my desk last week from the Department of Palliative Care at Geisinger Medical Center, I drew this important insight: "Do not use pain intensity as the primary outcome in the management of chronic pain." 

Sounds pretty simple. But what do we use, then? Perhaps a greater focus on concepts like "pain acceptance" will help us break through the chronic pain conundrum.

Michael Gavin is president of Prium, a medical managed care provider for the workers' compensation industry. This column was reprinted with permission from the firm's Evidence Based blog.