Something for the Pain: Where is the opioid crisis headed?

The air freshener at The Cosmopolitan resembled a middle-school dance: a crush of Axe body spray and sweat. There were low lights beneath fabric swags; strings of crystal draped from the ceiling. The floor sparkled, opulent, and the casino hummed dark inside. Every wall and piece of furniture was decorated in purple, gray, or black—like a nightclub, or a bruise.

Las Vegas felt a little too on the nose for a pain conference, but here we were: over two thousand frontline practitioners gathered together for PAINWeek 2019, the largest medical conference in the country devoted to this specific genre of suffering, held at The Cosmopolitan for nearly ten years. Outside, it was September on the Strip, hot enough to melt your sandals to the sidewalk. Inside, it was impossible to miss the promotional blitz for a show titled OPIUM.

I was here because I'd heard that chronic-pain patients across the country were being denied their medication. Ever since the CDC had issued guidelines in March 2016 indicating a daily-dosage ceiling for opioids of ninety morphine milligram equivalents (MMEs) per day, in most cases, the pain community had been in an uproar. Most pain-medicine healthcare providers found this limit alarmingly inadequate; they often saw patients who were stable on much higher doses or even double this number. With the new guideline, many practitioners were forced to taper their patients down to a smaller dose or off opioids altogether, which, though politically responsive, felt medically negligent. Many pain physicians were frustrated by the degree to which opioids and the health-care providers who prescribe them had been unfairly demonized.

Opioids were just one of several tools that health-care providers used for pain management, but many of the others had become less popular in recent years, or weren't covered by insurance. The potential problem of opioid abuse was managed in a variety of ways, some of which were highlighted at the conference. There were sessions on abuse-deterrent drugs, on alternative medicine, information on dosing practices, a panel on urine drug screening for pain patients, among many others. Essentially, if your patients were abusing drugs, there were plenty of strategies to deter them, treat their pain, and still retain your medical license in the process.

In the Brera Ballroom that first morning, breakfast consisted of a fruit smoothie, a breakfast burrito, coffee, orange juice, and pastries. The program I wanted to see—Managing Chronic Pain with Abuse-Deterrent Extended-Release Opioids: Clinical Evidence and Implications, sponsored by Collegium Pharmaceutical—was scheduled for 8:30 A.M. At the door, representatives from Collegium had scanned our badges so the transfer of value associated with this breakfast could be reported in accordance with the Sunshine Act, a US health-care law that requires disclosure and tracking of financial relationships between pharmaceutical companies and healthcare providers. These types of programs were a mainstay of medical conferences, in which a "key opinion leader," generally a physician or physician assistant, or nurse practitioner with a lot of influence, talks about the latest and greatest in better living through chemistry. Over breakfast burritos and soggy pastries, you took in a series of slides with pharmacokinetic data, maybe a phase 4 trial, some safety profiles. That morning's program covered a drug called Xtampza ER. The main discussion at many of these breakfasts at PAINWeek was around abusedeterrent opioids, extended-release versions of drugs that became less effective if you crushed and snorted them or injected them or took them in any way other than the way they had been prescribed. This path of abuse deterrence had become popular among pharmaceutical companies as a way to hedge against the opioid crisis; the first reformulation for OxyContin occurred in 2010, when Purdue Pharma made the drug harder to abuse. What wasn't described during our sponsored breakfast, but mentioned later in other panels, was the spike in...