Blog | Friday, October 6, 2017

The slippery slope of opioid prescribing


I hate dealing with opioid pain medications. They are one of the worst parts of being a primary care doctor. Many patients come to my practice on chronic opioids, expecting me to continue these medications. Other patients have the expectation that any pain should be treated with a narcotic. Some people sell the stuff, others continue in current pain despite being on daily medication. There are contracts to be signed, urine to be tested, and pain management doctors to consult, most of whom don't prescribe narcotics.

Nobody is happy. It is absolutely miserable.

The solution for this problem that many doctors take is to not prescribe any pain medications, leaving patients to seek out someone who will. This takes the huge headache away from that doctor, but creates significant problems to patients who have been on these medications chronically. Beyond that, it creates a culture of suspicion, as patients are often assumed to be manipulating to get more and stronger medications.

While there are certainly some who are aggressive and deceitful in their attempts to get narcotics, many others (most, in my opinion) are led down this path without their knowledge. It goes something like this:

Step 1: Patient has legitimate pain and is given a pain medication.

Step 2: Pain medication helps with pain, and has an added bonus: a euphoric effect, which the patient equates with pain relief.

Step 3: Patient develops worse chronic pain, and is put on a regular but low dose of narcotic, getting some pain relief but acquiring a desire for the euphoria (which also helps deal with life stressors, etc.)

Step 4: Patient develops a tolerance to the narcotic, requiring higher dose to get same pain relief/euphoric effect.

Step 5: Eventually patient gets to a high enough dose of narcotic that they have significant withdrawal if they miss a dose or two, making the “need” for medication even stronger. This all happens while they are not getting adequate pain relief due to tolerance.

So is the patient nefarious in their actions? No. They have legitimate pain that they want treated, and are brought down a path to a place where they not only have that pain, but also have a dependency on a dangerous drug.

The doctor may have been well-meaning at the start, but becomes careless, putting “keeping the customer satisfied” as a top priority. This isn't nefarious either, given the time it takes to educate people in this subject and the small amount of time each primary care doctor has for actual patient care. It is too difficult to do the right thing and to address the pain properly (or explain that pain should be expected and doesn't always need treatment).

A study presented at the American Academy of Pediatrics meeting in Chicago found that many adolescents become chronic opioid users after having common surgeries. Legitimate pain (from surgery) leads kids into the slippery slope of chronic pain medication use. It certainly doesn't seem unreasonable to give medication for postsurgical pain, yet this is a potential gateway to the dark world of dependency and addiction.

We need to change our views on the use of these medications. I was taught that a patient with acute pain was not high risk to become abusers. I was also taught that it was our duty as doctors to treat pain. Allowing a person, much less a child, to suffer in pain seems to go against compassion. But it seems that this misguided compassion is actually causing significant harm.

The view of our society also needs to change regarding pain. I regularly have people with routine problems (back injury, ankle sprain) who request opioid pain medication. But pain is simply a part of our existence, and our desire to block out all pain with medications leads to even more pain in the end.

The solution isn't to vilify the person on narcotics or the doctor prescribing them. The solution is to realize that pain should be an expected part of life, and learning to live with it is far better than to cover it up with substances. We also need to understand that nobody is safe (as this study demonstrates).

I do think there is a place for these medications (I certainly appreciated them when I fractured my humerus), but they need to be treated as a last resort, not a routine approach to pain. They need to be reserved for severe acute pain, and should be very closely monitored and limited. This isn't easy for those of us taught to see pain as a “vital sign,” and were taught that acute pain should be treated.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.