Prescribing Opioid Analgesics Amidst an Epidemic of Abuse
A Responsible Pain Physician’s Perspective on Prescribing Opioid Analgesics Amidst an Epidemic of Abuse
In the 1990’s, the American Pain Society-sponsored physician lecturers and other “so-called experts” were indoctrinating practicing physicians with the erroneous notion that opioid analgesics were safe for long-term use. Pain was rebranded as the “fifth vital sign” and physicians, who were not more aggressively treating chronic pain NOT associated with cancer with opioid analgesics, were considered to be or frankly accused of potentially mercilessly depriving their patients of compassionate and appropriate care. We were hoodwinked into believing that risks of addiction were very low. We were visited by armies of pharmaceutical company representatives who brought us lunch and paid for expensive dinners with featured pain experts who were funded by Big Pharma. I bought the sell job. Most doctors did too. More recently, we learned of the opioid manufacturers, aided by a corrupt federal justice system, pushing physicians hard to provide prescriptions for high-dose long-acting opioids like oxycodone, fentanyl, oxymorphone, morphine, etc. The rest is as you have read and seen on TV.
From the late-1990’s and into the early 2000’s, I witnessed the blossoming of the crisis. Patients were abusing and diverting opioids to buy other drugs of choice and becoming addicted to opioids and tranquilizers. I remember calling the Pottstown police department, in light of the huge influx of patients who came to see me in Philadelphia from afar, about patients who I discovered were diverting opioids. I couldn’t believe it, but there was nothing I could do to report and curb this nefarious behavior. There were no mechanisms in place to put a stop to it.
I began to educate myself about managing challenging pain patients and put together an action plan that eventually was formalized and became the subject of a lecture that I gave in 2005 at the American Academy of Physical Medicine and Rehabilitation’s Annual Assembly in Phoenix. Standing room only! My and other physician efforts at the time represented the leading edge of the physician response to the developing crisis that, unfortunately, didn’t get named until later 2016! For years, I battled the rising tide and actually suffered a reputation of being uncompassionate as I tested my patients’ urine samples, took pill counts, declined refilling opioids with occurrences of aberrant illness behavior, and cut patients off entirely from controlled medications when they appeared to be entirely disinterested in doing anything to help themselves, other than appearing in my office for opioid prescription refills. Since those times, my vigilant behavior has been vindicated.
At this point, the academic, licensing, and insurance institutions have done an about face … and strongly support sometimes seemingly draconian measures to curtail opioid and tranquilizer (benzodiazepine anti-anxiety medication) prescription. Occasionally, it feels as though some patients are being vilified and suffer the punishment for the prior sins of others. The current guidelines practically mandate that opioids are prescribed for only 1 or 2 weeks after acute trauma and/or surgery and then are weaned off. Some research supports prescribing only short-term anti-inflammatories and Tylenol as equivalently effective analgesia compared to opioids in the chronic pain setting. In fact, it has become clear that opioids are poor choices when it comes to treating neuropathic pain, which is the more common residual pain pattern in the chronic setting.
Indeed, I have taken upon myself to always try to reduce opioid dosing by optimizing general wellness and by preferential prescription of adjuvant analgesics like tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors (also antidepressant medications), anticonvulsants (that primarily treat seizures), and anti-spasmodics. I am a tireless cheerleader, trying to get smokers to kick the habit in creative ways. I help my patients follow anti-inflammatory diets, restore their sleep as possible, encourage a manageable exercise regimen, manage stress sensibly, and optimize vitamin D levels. Fortunately, I have gotten many patients to wean off opioids entirely. In many instances, I and my patients have discovered that opioids were not helping reduce pain at all. The medications were causing significant side effects including decreased cognition, memory, and mood and endocrine abnormalities (thyroid and gonadal suppression) with fatigue and loss of libido and sexual function, while offering little to no benefit.
Yes, there is still a sometimes very powerful and positive role opioids play – in getting pain under fair control while instituting many of the other non-opioid treatment options as described above … until they can be weaned as promptly as possible. Psychological dependence on opioids develops quite rapidly and we physicians must be vigilant in avoiding this. By being thorough in taking a comprehensive history and doing a complete musculoskeletal and neurological examination, diagnoses may be identified more readily and rapidly, and the most effective definitive treatments may be instituted without delay, obviating the need for pain medication altogether. That is my goal – which, when achieved in partnership with a patient, is most gratifying!
