There is no doubt that there is a problem with opioid abuse in our nation. However, the answer is not to enact reactionary laws and restrictions that make it harder for patients with a legitimate need to receive their medication. The conversation about opioids has been focused on acute patients and those who have had surgery or an injury, but has neglected to mention the unintended victims of anti-opioid campaigns; chronic pain patients who live in agony and will most likely need medication for the rest of their lives.
Neglected also is the fact that the majority of abuse of prescription opioids takes place outside of the doctor-patient relationship. From the World Health Organization Normative Guidelines on Pain Management1– “Fear of development of drug dependence and diversion interferes with opioids prescription. It is known that de novo development of drug dependence syndrome when opioids are used for treatment of pain is low.2 Studies have indicated that the physician prescribed opioids are not the primary source of diversion.3 The theft from drug distribution chain is an important source of diversion of pain medications in the United States.4“
The CDC, along with other organizations and federal and state governments, has overstepped its bounds by releasing a set of “guidelines”5 for opioid prescription. Although the guidelines do not prohibit the prescription of opioids, recent pressure and legislation increase the complexity and effort involved in prescribing them. This has had the same effect as declaring them illegal. My research has shown me that many doctors have decided to declare that their policy is to not prescribe opioids at all because it is easier. I can’t even get my case heard; most doctors I’ve talked to flatly state that they don’t prescribe.
I recently saw a pain doctor at one of the best hospitals in the country and was told that their policy is to “not prescribe opioids to non-cancer patients.” When asked what I should do, since in my case other methods either have not worked or cannot be used due to side effects, he said he did not have a suggestion and wished he could prescribe them for me, but was unable to. In my opinion, most of my doctors have chosen the easy route by implementing a blanket policy of refusing to prescribe pain medication at all, rather than treating each patient as an individual with unique needs. Some patients, due to the CDC guidelines, are now being forced to undergo monthly drug tests for no reason other than that they are taking opioids. Forcing someone to take a drug test in order to receive treatment with no reason to suspect abuse is shameful and should be prohibited. Even our criminal justice system treats suspects as “innocent until proven guilty,” but the same logic does not seem to apply in this case. Some patients are having their dosages reduced in response to the CDC guidelines, and some are left with the heart-wrenching prospect of having their medication completely cut off.
Let me repeat; this is as a result of nothing more than public and government pressure, not because these patients have done something wrong. I have personally had a pharmacist at a major chain refuse to fill my prescription and lie about the reason why, and then make negative comments about it to my face. I have had several doctors express concerns about legal action and increased government interference in opioid prescription, and cite these as reasons for not prescribing.
In my conversation with the pain specialist I recently saw at a major hospital, he gave me several reasons that doctors are now hesitant to prescribe opioids. Number one, of course, was public and government pressure, followed by increased complexity and the fear of losing his license. Other reasons were risk of addiction and lack of an “equation” to tell doctors what and how to prescribe.
It’s crucial here to draw a distinction between addiction and dependence. According to the National Institute on Drug Abuse, “Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain; they change its structure and how it works…Physical dependence is not equivalent to dependence or addiction, and may occur with the regular (daily or almost daily) use of any substance, legal or illegal, even when taken as prescribed. It occurs because the body naturally adapts to regular exposure to a substance (e.g., caffeine or a prescription drug). When that substance is taken away, symptoms can emerge while the body re-adjusts to the loss of the substance. Physical dependence can lead to craving the drug to relieve the withdrawal symptoms. Drug dependence and addiction refer to substance use disorders, which may include physical dependence but must also meet additional criteria.”6 It would be beneficial to consider the risk of addiction as any other potential side effect, such as risk of heart, liver or kidney disease, osteoporosis, tardive dyskinesia, etc., none of which stop doctors from prescribing other medications.
As far citing as lack of an “equation” on how and when to prescribe as a reason for not prescribing, I allege that this is a faulty argument. Psychiatric drugs, for example, do not have such an equation or rubric—this is left up to the doctor’s discretion, as it should be. I have been denied coverage for a treatment because my condition was not on my insurance company’s list of those approved to receive this treatment. Therefore, someone who had never met me decided he or she knew better than my doctor (and I) what potentially life-saving treatment I could receive. This is exactly what is happening here.
I also want to point out that doctors often suggest “alternatives,” such as cognitive behavioral therapy which is usually not covered by insurance, acupuncture, which is almost never covered, and physical therapy, which becomes very expensive even with insurance if you are going several times a week for months. Alternative treatments such as medical marijuana are not covered and are prohibitively expensive. These alternative therapies, while of course worth trying, do not help everyone. Consider also the pain that prevents patients from being able to leave their house to even get to these appointments, and to do physical therapy.
If the medical industry and government are really serious about promoting these therapies, they should be made affordable or incentivized. Funds should be allocated to development of non-opioid pharmaceuticals. Continuing to say “opioids are bad!” and promoting restrictive laws does not stop illicit users and only hurts those who need them. These decisions should not be made by insurance companies or the government, they should be up to the individual physician and patient. I have been told by a pain doctor that “we are just not good at treating pain” and that he often hears stories like mine, where patients are told they shouldn’t be taking opioids but are not given any alternative.
A few closing thoughts. The World Health Organization has issued guidelines on the prescription of opioids in malignant pain and in non-malignant pain in children. They have been working on guidelines for opioid prescription in chronic non-malignant pain, and have currently released a few scoping documents and studies, such as the aforementioned World Health Organization Normative Guidelines on Pain Management, which states, “They [health professionals] must not be afraid of the early use of opioids in moderate and severe pain, which is better than NSAIDs which cause gastric bleeding, kidney and liver failure etc.,” and that, “Fear of development of drug dependence and diversion interferes with opioids prescription. It is known that de novo development of drug dependence syndrome when opioids are used for treatment of pain is low. Studies have indicated that the physician prescribed opioids are not the primary source of diversion.”1 In absence of formal WHO guidelines, why can the current WHO analgesic ladder not be used? Surely this would fulfill the request for an “equation” for opioid prescription.
I have a feeding tube that was surgically placed and has forever altered my body. I have an open wound that causes pain and infections. The surgery carried risk, the act of changing the tube every few months carries a risk, the tube’s mere presence is a risk. And yet, it’s worth the risk because it keeps me alive. My pain medication takes the life that the tube has saved and makes it a life worth saving.
The medical industry does not have to bow to public pressure. This is the time for doctors and patients to stand up and reject reactionary responses. I encourage the medical industry to come up with other affordable methods for pain management. But until then, do not take away the only relief many of us have.
1 World Health Organization Normative Guidelines on Pain Management, Geneva, June 2007, Report Prepared by Prof. Neeta Kumar, Consultant, WHO, Geneva http://www.who.int/medicines/areas/quality_safety/delphi_study_pain_guidelines.pdf?ua=1
2 Blake S, Ruel B, Seamark C, Seamark D. Experiences of patients requiring strong opioid drugs for chronic non-malignant pain: a patient-initiated study.
3 Kline AT, Smith MY, Haddox et al. Abuser reported sources of illegally obtained opioid medications. American Academy of Pain Medicine 23rd annual meeting, Feb 7-10, 2007, New Orleans, Louisiana, abstract 105
4 Joranson DE, Gilson AM. Drug crime is a source of abused pain medications in the United States. Journal of Pain and Symptom Management. 2005; 30(4):299-301
5 Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
6 NIDA (2016). Media Guide. Retrieved February 9, 2017, from https://www.drugabuse.gov/publications/media-guide