Do Opioids Work For Chronic Pain?

The NPR program Fresh Air broadcast an interview earlier this week with New York Times reporter and author Barry Meier discussing his e-book A World of Hurt: Fixing Pain Medicine’s Biggest Mistake.  While Meier notes that opioid medications, such as OxyCotin, are valuable medications for patients recovering from surgery or serious accidents, he cites several sources indicating that, over the long term, these medications are actually harming those who take them.  Opiod drugs do work in the short run, providing strong pain relief, but over the longer term they stop working and leave people dependent upon the medications. At higher doses, the drugs also impair people’s ability to focus and think and can result in lowered engagement with life.

It appears that this author is not alone in his opinion.  Dr. Mel Pohl, a specialist in addiction medicine, has written very similar sentiments.  In fact, he writes that “at a recent two-day public meeting of the Food and Drug Administration (FDA) pain doctors and researchers were in agreement that there is a lack of scientific evidence to support that opioids are effective as long-term treatment for persistent pain.”  He goes on to say that ”some doctors believe, as I do, that long-term opioids are not helping most people.”
So What’s The Solution?
Both Dr. Pohl and Barry Meier reach the same conclusion for how to effectively address the complex issue of treating chronic pain – higher use of proven non-drug approaches to pain management.  As Dr. Pohl writes “It is unlikely that we will find the right drug or drugs to treat our pain and suffering effectively. There are many alternative treatments that may be effective for chronic pain sufferers.”  Approaches like Acceptance and Commitment Therapy, an innovative form of cognitive behavioral therapy, show people that chronic pain does not have to run their life.  Acceptance and Commitment Therapy has received the highest stamp of approval of “strong research support” as an evidenced-based approach to chronic pain by the Society of Clinical Psychology. Acceptance and Commitment Therapy is an example of the kinds of tools that people can learn to effectively manage and live with pain in ways that work much better in the long run than relying solely on opioid medications.

What’s love got to do with it? Arguments for the use of “love drugs” miss the point

“Oh what’s love got to do, got to do with it?
What’s love but a second hand emotion.”
Tina Turner, singer

That spark gone between you and your partner? No need for couples therapy. Struggling to find love? Forget Science hopes to bring you a new solution to all your love woes… “Love Drugs.” Could it be possible that we could just take a pill that would make us fall “in love” or fall “out of love” with someone? Maybe. To me that question misses the whole point.

This topic came to my attention a few weeks ago as I was listening to a radio program on the Canadian Broadcasting Corporation. The host was interviewing Brian Earp, MSc., an ethicist from Oxford who is writing a book on the “neuroenhancement” of love and marriage. In the interview, which you can listen to here, Earp cites research into the use of synthetic versions of various neurochemicals including oxytocin and dopamine which are purported to increase feelings of “love” and bonding in both human and non-human animals. The crux of Earp’s argument for the use of such drugs is essentially that we humans are not “naturally” monogamous animals and thus these drugs can help couples work against that “nature” in order to maintain monogamous relationships.

Earp’s colleagues at Oxford, Savulescu & Sandberg have written an interesting article in the journal Neuroethics in which they review what they think are the arguments for and against the use of such drugs.  While they ultimately come down on the side of supporting the use of such “love”-enhancing drugs, some of the arguments they cite against the use of such drugs include concerns about addiction and adaptation, the risk that they could be used in a non-consensual or coercive manner, and questions about whether or not the feelings produced by them could be considered “authentic.”

To me, these aren’t the most important questions. For the purposes of this post, I’m going to set aside the whole issue of whether or not we as a society should only value one form of relationships–monogamy. That’s for another post at another time. An even more basic question can be summed up by the wise philosopher known as Tina Turner: “What’s love got to do with it?”

Earp and his colleagues’ whole argument is based on the idea that “love” is a feeling. Furthermore, from their point of view, it’s the feeling of “love” that determines our behavior. However, contextual behavioral scientists (CBS) (a group which would include ACT therapists) suggest that it might be more useful to view “love” as a verb, as a series of behaviors in which we are free to engage at any point, without needing a particular feeling first. Coming from a CBS framework, since feelings are largely out of our control, assuming that a particular feeling must be present in order to engage in a valued behavior is simply an unworkable assumption.

If you’ve lost me in the science speak, hang in there with me. Here is the point… As both a scientist and a human, I truly don’t care if my partner feels like he loves me, especially since I would contend that his feelings are simply the result of various neurochemicals in his brain and thus he isn’t freely choosing to have or not have them. Rather I care that he IS loving to me. Love as a verb, not a feeling. And if I say I “love” my niece and nephew, what I mean is that I choose to be loving towards them, to treat them with kindness, protection, and patience, even when they are being difficult or mean and I don’t really FEEL loving towards them. Love often occurs during those times when we don’t necessarily feel loving, when we don’t feel an emotion that Earp and his colleagues would call “love”.

This is an age-old problem in the field of psychology. We are told that we need to work on feeling a particular way in order to behave in a particular way. You can see examples of this message all over our society. You need to feel good about yourself and then you’ll treat yourself well.  You need to feel less depressed or less anxious and then you can engage with life in a way that would be meaningful and vital for you. You need to feel “love” in order to be in a loving, committed relationship. I maintain that these are unworkable assumptions. Instead of having changeable feelings in the driver’s seat, I’m interested in helping people to live and love well and take the feelings along for the ride.

For me, rather than arguing whether the use of “love drugs” is ethical, I would say that it’s simply part of an unworkable assumption. I would rather help people explore whether, if they were completely free to choose (not based on what society says and not based on the particular feelings or urges they happen to have at this moment), would they choose to maintain a committed relationship? If this is a value that they would choose, then I want to work towards helping them live that value, regardless of passing feelings, feelings produced by synthetic chemicals or otherwise.

Ketamine for OCD, Too?

I’ve written in the past about the use of a pharmaceutical version of the drug ketamine (known as the party drug, “Special K”) in studies with depression and with bipolar disorder. Recently, I learned researchers have published a new study looking at the impact of ketamine on obsessive compulsive disorder (OCD).

I was on the phone with someone interested in OCD treatment, and she mentioned she had read some promising work at Yale about an experimental treatment that involved increasing glutamate levels in people with OCD. Glutamate is a neurotransmitter in the brain. Ketamine affects NMDA, an important receptor for glutamate, leading to lower levels of glutamate in the brain. I told the caller I wasn’t familiar with this line of research, and she kindly sent me a few links, including the one below.

The IOCDF article
The International OCD Foundation (IOCDF) has an article on their website about the potential role of glutamate in understanding OCD, under the subheading, “Cutting Edge Research on New Medication Options.” It’s written by three doctors associated with Yale University. The authors summarize some research finding higher levels of glutamate in the brain in people with OCD. Although they acknowledge important caveats about what is known about glutamate so far, the authors end the article with pointing to ketamine as a possible treatment for OCD.

The article is reasonably balanced, but at the time it was written, there was no published research on the use of ketamine in people with OCD. A study from 2012 suggests these speculations may have been overly optimistic.

A 2012 research study
I haven’t been able to track down a copy of the full article, so my comments are taken strictly from the abstract. Two of three authors from the IOCDF article are authors on the study. The details are a little unclear but the take-away message is pretty explicit:

“Ketamine effects on OCD symptoms…did not seem to persist or progress after the acute effects of ketamine had dissipated.”

It appears that the effect of ketamine on OCD was very small, and it didn’t last very long. It looks like the enthusiasm in the IOCDF article could use some updating.

Some concluding thoughts
I’d like to be clear that I think the authors of the IOCDF articles are well-intentioned, honest, and excellent researchers. What’s important to keep in mind is that the history of science is littered with ideas that seemed sound or were based on preliminary research, but which were disappointing when studied through controlled research.

As I’ve noted in my other writings on ketamine, I don’t object to ketamine being studied; however, I think researchers should be more cautious about their enthusiasm when talking to the public. Science is a slow progress of trial-and-error, and truly revolutionary treatments are few and far between. Ketamine may yet emerge as useful for depression, but if this study is any indication, its role for OCD doesn’t look very promising.

That said, there’s some exciting research on improving psychotherapeutic approaches for OCD. Cognitive behavioral therapy isn’t as exciting as the promise of a fast-acting drug, but it is effective and the best thing we have for OCD, particularly exposure therapy, something I’ve written about in our therapist blog.