When the US Pain Foundation recently surveyed 2,378 individuals to better understand the public health crisis of chronic pain, 42% of the respondents said that their top policy issue is the want for new medications for chronic pain. But while there are exciting developments in new therapeutics for migraine conditions, the current state of chronic pain medication as a whole has lagged behind.
“There is a disconnect, an enormous unmet need of treatments for these patients, and there’s the issue that chronic pain isn’t necessarily taken as seriously as other diseases are,” says James Campbell, MD, Professor Emeritus of neurosurgery at Johns Hopkins University School of Medicine, author of over 100 peer-reviewed scientific studies in the field of pain research, and founder of the American Pain Foundation. “But that can change: the advocacy community, the patients that are speaking up, are extraordinarily important, because it’s part of letting others know what the impact is and the importance of chronic pain.
That enormous need came across in the results of the US Pain survey: 24% of those who responded said no side effect would prevent them from trying a medication to manage pain. Campbell encourages patients to visit clinicaltrials.gov and search for a study they’d qualify for: trials like these are the only way to show whether a drug works, and may mean you get access to a helpful medication before it’s FDA approved.
A Breakthrough in Migraine Therapeutics
The most promising innovation in recent years is the approval of a new class of drugs used to treat migraine disease, the first such new treatment in decades. While the full causes of migraine are not yet understood, in recent years scientists have observed that a calcitonin gene-related peptide (CGRP) is elevated during a migraine attack, while someone with chronic migraine has chronically elevated levels of this neurotransmitter. This new class of medications, referred to as CGRP inhibitors or antagonists, work using monoclonal antibodies, which target the CGRP protein or its receptor. Many patients saw a significant reduction in the frequency of their severity of their migraine after taking one of these new medications.
Glimmers of Hope
“You know the old metaphor about how the squeaky wheel gets the grease?” says Campbell. “People who speak up and work through advocacy organizations are a major factor in what happens at a policy level. If the only thing that gets told is about overdose deaths and addiction issues, well then, that’s how pain will be thought of. But the reality of what a person goes through in suffering from chronic pain — it’s very important to get that word out.”
One glimmer of hope for pain patients was the launch of the National Institute of Health’s HEAL (Helping to End Addiction Long-term) Initiative, a multi-year, multi-agency effort funding major investments into the science of pain. Some of the goals of this program include stimulating the development of new therapies and treatments for pain, funding research relating to the opiate crisis, and making major investments in understanding the biological underpinnings of chronic pain.
“What’s happening at the NIH is hugely important, and I think it will pay off in the long run, but it’s important to understand that this requires a persistent dedication,” says Campbell. “These things don’t occur overnight, so people have to be patient and to believe that these investments will pay off in time.”
New medications, novel applications, and ‘me too’ drugs
It can be a long and complicated road to get a new medication approved by the FDA. Unfortunately, the really novel drugs that have been in trials for the past two decades “have almost uniformly failed,” says Campbell. This lack of progress can be cyclical: as investors failed to see a return on their investment in new therapeutics for chronic pain, they decided to put their money into different areas of health care.
In fact, the ‘new’ medications available for chronic pain in recent years have actually been novel uses for drugs already previously approved by the FDA. Many of these new applications have come as a result of serendipity, just happening to find a helpful side effect: of medications now frequently prescribed for pain relief, duloxetine was originally approved as an antidepressant, while gabapentin and pregabalin were originally approved as anti-seizure medications. Another class of meds, “me-toos,’ involve “just small tweaks on old themes,” says Campbell.
Communicating the Reality of Pain
With a lack of truly new options, that reality is that it can be easy for chronic pain patients to get discouraged. Campbell urges patients to persevere and seek a second opinion if their pain isn’t being adequately treated: many doctors, especially general practitioners or family medicine doctors, may not even be aware of the range of options currently available for pain treatment.
Unfortunately, there are always modern day snake-oil salesmen out there promising the moon— or at least, pain relief that’s out of this world. But if it sounds too good to be true, then it probably is. All medications have potential side effects, and when you see claims like a money-back guarantee “the public should know that language like that most often hides bogus claims,” says Campbell.
The Future of Therapeutics for Chronic Pain
Despite some glimmers of hope in areas like chronic migraine and research, in recent years there have been very few true developments in the field of therapeutics for chronic pain as a whole. Chronic pain patients can advocate to change this by speaking up, sharing their experiences, and changing the narrative around chronic pain. “These stories need to be told over and over again,” explains Campbell. “When advocates articulate their stories and get this information out there, it does have an impact.”
“As a physician and scientist trying to work on new therapies, I’m dealing with scientific principles and abstract concepts. I can say things, but a patient speaks from experience—and that’s often far more impactful.”