Expert: Advances in pain care overshadowed by opioid risks, evidence gaps

June Dahl, professor of pharmacology at the University of Wisconsin School of Medicine and Public Health, told attendees at the Montana Pain Initiative conference in Missoula that the U.S. has seen major advances in pain assessment and treatment but faces serious open questions about opioid safety and long-term effectiveness.

Dahl said pain is widespread and often undertreated, citing published estimates that place the economic burden of common pain conditions including headache, back pain and arthritis at about $61,000,000,000 a year. She also highlighted changing cancer survivorship, saying millions of Americans now live longer with cancer-related pain and that pain among cancer survivors is becoming a long-term, management problem rather than an exclusively end-of-life issue.

Why it matters: Dahl framed those trends as central to the work of the new Montana Pain Initiative. Improvements in measurement, multimodal therapies and palliative-care programs create opportunities to reduce suffering, she said, but mounting opioid-related harms and gaps in high-quality long-term evidence complicate clinical and policy choices.

Dahl reviewed historical and recent milestones: multidisciplinary pain clinics, the World Health Organization’s cancer pain relief guidance and the Joint Commission’s pain-assessment standards. She credited large philanthropic investments and targeted federal grants for accelerating palliative- care programs and clinician training, but noted a continued mismatch between knowledge and practice.

On opioids, Dahl emphasized their “dual nature.” She said opioids remain essential for many kinds of acute, post-operative and cancer pain, and can help selected patients with persistent noncancer pain. At the same time she noted rising abuse and opioid-related deaths nationwide and said the data on long-term outcomes are limited. Dahl cited a large observational study from Denmark that found no clear functional or quality-of-life benefit for opioids in persistent noncancer pain after accounting for confounders.

Dahl also discussed public attitudes reported in the Montana white paper: roughly a third of respondents said they believe most people taking pain medicine will become addicted or that people get addicted easily, and roughly a quarter reported worrying about tolerance. She said those perceptions affect both patients’ willingness to use medicines and clinicians’ prescribing behavior.

Dahl described a set of regulatory and professional developments that aim for balance: joint statements from the Drug Enforcement Administration and other federal and professional bodies stressing both pain relief and abuse prevention, Federation of State Medical Boards guidance, and state-level analyses by the Pain and Policy Studies Group. She called attention to a frequently cited finding that pain-related research received a small share of National Institutes of Health funding (Dahl cited a prior analysis that estimated about 1 percent of NIH budget going to pain research) and urged more investment in rigorous long-term studies.

“Never doubt that a group of thoughtful, committed, a little bit crazy people can change the world,” Dahl quoted toward the end of her talk, urging attendees to turn conference findings into concrete, local action.

Dahl’s remarks set the technical and ethical frame for Montana’s planning work that followed at the conference: measurement and multimodal care are available tools, she said, but implementation will require confronting workforce limits, reimbursement gaps and the uncertainties around long-term opioid therapy.