With opioids, can you fight addiction without causing pain?

Opioids are deadly, killing more people in Massachusetts than either guns or car crashes. Yet they are also vital pain relievers, easing the suffering of millions struck by cancer and other calamities.

The state’s Promethean challenge is to stop opioid abuse from shattering more lives without turning severe pain into its own, untreatable scourge.

A new anti-opioid bill currently working its way through the Legislature tries to strike this difficult balance, with restrictions designed to ensure that doctors can treat pain without risking addiction. But an innovative new economic analysis shows how difficult this task really is.

Looking at prior efforts to monitor and curtail overprescription, the study finds that while lives were doubtless saved, many people were left unable to cope with their pain, including workers who couldn’t return to jobs and patients who were forced to seek out other, sometimes expensive forms of treatment.

Side by side, it isn’t clear that the benefits of opioid management really outweighed the costs of untreated pain.

How bad is the opioid crisis in Massachusetts?

Quite bad, and growing worse.

Just Wednesday, Brockton reported 16 overdoses, bringing a two-day overdose tally in that city to 25. None of the overdoses were immediately fatal, officials said.

Since 2010, the number of opioid-related deaths in the state has more than doubled, from just over 500 per year to well over 1,000.

That includes both heroin and prescription opioids, but even if you separate them out, you can see that both rose starkly in 2014, suggesting that the problem really does cut across the two categories.

Have the state’s anti-opioid efforts been working?

In 2010, the state implemented a prescription drug monitoring program to cut down on inappropriate opioid prescriptions and help doctors identify drug-seeking patients.

These programs really do seem to save lives. When Angela Kilby, a graduate student in the MIT economics department, measured the impact of prescription monitoring programs across the country, she found that they save about 1,000 lives per year. Some of those saved lives surely belong to Massachusetts residents.

The logic behind this success is clear. Prescription monitoring programs cut down on prescriptions, which translates into fewer pills and ultimately fewer deaths. The chart below shows how closely these things are related.

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What about pain?

Whether it’s Oxycontin, Percocet, Vicodin, morphine, or codeine, some 75 million Americans get opioid prescriptions each year to help them recover from injuries or surgery, or deal with chronic pain that doesn’t seem to respond to other medications.

When you make it harder for people to get these drugs, their pain doesn’t magically go away. In fact, it seems to get worse.

Kilby measured this in a couple of different ways. Most directly, she looked at a common hospital survey, which asks patients how satisfied they are with the way their pain was treated. She found that once a prescription drug monitoring program goes into effect, patients become less satisfied with their pain treatment.

Kilby also looked at injured workers who apply for workers’ compensation. There again, she found that after states started monitoring opioids, injured and ill workers were apt to need more recovery time.

Both these findings point in the same direction: When monitoring programs start, pain management gets worse.

Isn’t saving lives more important than easing pain?

This is a very old, and very difficult, philosophical question: how do you measure the value of a human life? And can you weigh that life against other things — in this case, pain. Would you sacrifice one life if it meant a thousand people gripped by chronic pain were suddenly pain free? A million?

It’s common in public policy to estimate the value of a human life, in order to decide how best to spend public money (if you could save two lives a year by doubling everyone’s taxes, would you?)

Building on that approach, Kilby weighed the benefits of prescription monitoring programs against the cost. Her conclusion: The price of all that extra pain is substantial.

Best as we can measure it, the good done by saving lives and avoiding addiction treatment is roughly matched by the costs for alternative medical treatment and lost wages due to increased pain.

Should this change the way we fight opioid addiction?

It’s important to keep in mind that there’s much more to fighting opioid abuse than just the prescription monitoring program. Massachusetts has been pursuing a multi-pronged effort, including better treatment, reintegration programs, and easier access to the overdose-prevention drug naloxone.

Still, in this battle there are real trade-offs. And efforts to limit access to prescription drugs may well save lives, but they also leave people in pain.

The anti-opioid bill moving through the Legislature right now would further tighten the reins on doctors, making it illegal to start patients with anything more than a seven-day supply.

This may be the right balance to strike. But it’s important to think of it as a balance, because while opioids certainly can be deadly, they are sometimes also essential.

For many people living with acute pain, there is simply no good substitute, no treatment that is similarly effective and readily available.