We have two epidemics related to misuse of opioids in America. First: people with addiction and premature death from abuse of opioids. Second: also devastating but getting far less attention, people suffering for years from chronic unrelenting pain losing access to needed medicine. They are in more pain and experiencing terrible deterioration of their quality of life – unnecessarily.
Listen to a real patient I recently saw. At 55, he has suffered from severe, but well-controlled, pain for 10 years. He told me he was relatively OK, until his doctor told him "that there were new regulations, that my pain medications had to be cut down." He was taking them as prescribed, without abuse or side effects. They enabled him to live his life and enjoy his family, though he couldn't work.
With his medicine decreased, his pain increased. He was mostly homebound and needed a cane. Then it got worse. He told me, "I was shocked, and scared when my doctor said I had to find a new doctor; he wouldn't prescribe pain medicines anymore."
I hear this type of story multiple times every day in my practice. Fearful, teary-eyed patients, wondering what I, their new doctor, will be like. Harsh, judgmental, rushed, uncaring? Or perhaps, understanding?
Here's what I usually tell my patients (after a comprehensive history and exam, toxicology studies, reviewing questionnaires and databases which alert me to misuse): "There was no good medical reason to taper your medications. They were helpful and weren't abused. There aren't new regulations, rather, recommendations about not using higher levels of opioid medications unless there is a compelling reason. Chronic severe pain, and deterioration of quality of life, are significant compelling reasons, if the medicines help decrease your pain, and if no other treatments can accomplish this."
Patients frequently breathe a sigh of relief after this. As I begin to treat them carefully and act as their ally, most note decreasing pain and quality-of-life improvement. There are few greater physician rewards.
Opioids are prescribed in different clinical situations. In acute scenarios — tooth abscess, a bone fracture — a prescription should be limited. Overprescribing has frequently occurred in such cases. Patients with malignancies can develop severe pain, but for them, opioids are often underprescribed.
Then there are chronic-pain patients. Many have exhausted such options as physical therapy or had surgery without benefit. Physicians are backing away from opioid medications in all these situations. Why? Two reasons. First, with the harsh public spotlight, they are uncomfortable that they'll come under professional and legal scrutiny.
The second reason is it's complex and time-consuming to care for chronic pain patients. Opioids must be prescribed with proper knowledge and attention, or they can cause severe side effects, including death. When prescribed carefully to appropriate patients, they are commonly very helpful. If the goal is to adequately reduce pain and suffering, there are often no replacements.
The negative side of prescribing opioids, devastating and important, has been widely publicized. A survey last year showed that two-thirds of primary-care physicians had cut back on prescribing, though one-third believed that this was causing harm. Finding a new physician is becoming very difficult for chronic-pain patients. Many pain physicians don't participate in insurance plans. Many pain patients are disabled and poor.
Opioids are double-edged swords, with potential for great harm and great benefit. But will denying opioids to chronic-pain patients who have no other options solve the addiction epidemic? Unlikely. The solution doesn't lie here, and is only causing more suffering. These patients don't typically become addicts or overdose on opioids. The overwhelming majority of patients with chronic pain who are prescribed opioids by a trained, careful physician, do not abuse or sell their medications.
Do some physicians debate the efficacy of these medicines? Of course. This is usually when opioids are prescribed inappropriately to the wrong type of patient. For the observant physician treating pain, and for countless chronic-pain patients, there is absolutely no question that they can be beneficial.
There is great suffering brought about by the first epidemic of addiction and overdose. We are compounding this by inappropriate undertreatment of bona fide chronic pain patients. Physicians, and patients suffering from chronic pain, are caught in the crossfire. Still, physicians owe it to their patients – and to fulfilling medical vows – to help those who suffer.
Ira Cantor, M.D., is an internal medicine physician specializing in pain management at Steiner Medical & Therapeutic Center in Phoenixville.