In recognition that September is international Pain Awareness Month (“#MyPainPlan focuses on the vital importance of an individualized, multidisciplinary, multimodal approach to pain care”), I am republishing my August 3, 2017 LinkedIn blogpost entitled “Appropriate, Not Zero, Opioids.” It is as relevant and true on September 21, 2020 as it was when I originally wrote it. I hope it again re-centers our attention on the journey towards helping people live a full life in spite of their pain.
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From the mid-1990’s to the mid-2010’s, there has obviously been a huge change in attitudes about the role of opioids in managing pain. Before the mid-1990’s, their use beyond pre/post-op and end-of-life care was limited. In the mid-1990’s, the assertion was made that opioids were helpful for anybody with any pain at any time. With the resulting opioid (and corresponding heroin, illicit fentanyl and benzodiazepine) epidemics, in the mid-2010’s the pendulum is swinging once again to limited use of opioids. But is the pendulum swinging too far?
Pardon my ensuing over-simplification …
Going back to pre-epidemic uses, appropriate use typically meant before / during / immediately after surgery, cancer and end-of-life care (i.e. during the acute and sub-acute phase of pain). The vast majority of people that use opioids under these circumstances do not become addicted or even dependent since they realize the drugs are merely a temporary tool to return to function.
The use of opioids outside of the above circumstances (i.e. chronic pain) comes down to simply:
- Is there an evidence-based treatment plan, individualized for the patient?
- Were all non-pharma / non-opioid-pharma alternatives tried but unsuccessful?
- Has the doctor evaluated potential red flags (i.e. due diligence)?
- Does the patient have improved levels of function and pain control with opioids?
In other words, opioids should not be the first choice for treatment of chronic pain. If the answer to the above questions are “yes” then opioid use is potentially supported. If any answers are “no” then their appropriateness starts to become questionable.
But answering those questions is not as simple as it may seem …
- Some clinicians rely on their own education and experience rather than evidence based medicine or the latest clinical studies in order to make treatment choices, but it’s difficult for a patient to tell the difference.
- Some physicians and patients don’t fully understand all of the non-opioid pharma and non-pharma alternatives available, so they haven’t “tried” everything.
- Some prescribers don’t use – or even know about – tools like SOAPP-R or ORT or DIRE or PHQ-9 to perform the necessary due diligence before writing the first script.
- The manifold negative potential side effects of opioid use (hyperalgesia, hypo-gonadism, over-sedation, nausea and constipation, dry mouth, miosis, increased anxiety and depression, hallucinations, confusion, respiratory depression and death … just to name a few) can overwhelm the benefits.
- The term “function” is somewhat subjective, and “pain control” is definitely subjective, including the potentially unreasonable expectation of pain’s eradication.
In a perfect world, opioids are not needed for chronic pain and tools like walking, Yoga, mindfulness, cognitive behavioral therapy, an active lifestyle, proper nutrition and sleep are sufficient. I personally know a number of people for whom that is true. But there are some chronic pain patients for whom only opioids work. How many? Probably a smaller number than those for whom opioids create more issues than they resolve. But certainly not zero.
I had an interesting phone conversation yesterday with two people, Patti Young and David Cole, with chronic pain and opinions about opioids. They both have been actively engaged with my LinkedIn posts, and I wanted to engage their opinions beyond text on a website. Without disclosing their specific conditions and history, there were some things we discussed that offer helpful context:
- Some doctors (prescribers), other clinicians, hospital staff, media and the general public don’t understand the difference between dependence and addiction — So they use “addict” to describe everybody (read my January 9 blogpost, “Using ‘Addiction’ Properly“)
- Some of the stakeholders (clinicians, employers) don’t practice active listening with patients or spend the necessary time to fully understand what’s happening beyond what they physically can and cannot do in order to identify legitimate alternative pain management techniques and work options — Instead, they quickly draw generalized conclusions about “addicts” or “malingerers” or “catastrophizers” (read my February 8 blogpost, “Detox Tidbits“)
- Some prescribers do not understand the opioid (polypharmacy) tapering process or even how to determine whether it is necessary — This can create “cold turkey” or “too fast” crises (a gap that prompted my co-authorship of “An Analysis of Drug Therapy Tapering Guidelines” with Kimberly Vernachio, PharmD RPh in April 2014)
- Some patients don’t do their own research on pain management options and instead rely solely on what their doctor tells them — Not only does this foster passivity instead of engagement but the quality of advice depends upon the quality, experience and “bedside manner” of the adviser (watch this 7:32 video about “Placebo Effect“)
- Some prescribers misunderstand the opioid MED thresholds (50, 90, 120) in various guidelines as mandates instead of targets and pursue them vigorously without fully understanding the repercussions of poor/too fast dose reduction — Here’s a direct quote from a CDC FAQ that does not say zero opioids – “Regularly assess whether opioids are improving pain and function without causing harm. If benefits do not outweigh harms, optimize other therapies and work with patients to taper opioids“
- And, most importantly, everyone (the patient, their family and/or caregivers, their friends and co-workers, the clinicians, the payer, general society) is desperate to resolve the chronic pain — Which often creates an environment in which sub-optimal decisions are made that often lead to more problems
Note that I used “some” above instead of “many” or “most” or “few”. We don’t really know how many physicians, patients and payers do it well … and how many do not. All we know is that the opioid epidemic is causing death and destruction while creating a number of ethical dilemmas and unintended consequences that nobody in 1995 could have predicted.
With the overwhelming focus on addressing the opioid epidemic, some doctors no longer prescribe opioids. For anyone. In other words, zero. For additional context, read my June 15 blogpost “Are Opioid Restrictions Causing Harm?”
Some of that has to do with the ever tightening statutory restrictions by federal and state agencies along with updates to treatment guidelines in every facet of healthcare. Some of that has to do with the pursuit and prosecution of over-prescribers. Some of that has to do with news stories published on the Internet, on TV and in every city across the country about the unfolding human tragedy of the opioid epidemic. Some of that might even be the potential of violence (“A doctor was killed for refusing to prescribe opioids, authorities say“).
So it does appear that some doctors have been scared by all the talk about the opioid epidemic and are on defense. And it appears there are two options from which doctors can choose:
- Stop prescribing opioids and/or dismiss all chronic pain patients that use them
- Evaluate the appropriateness of opioids on an individual basis
While (1) may be pragmatic it will likely create harm. I think (2) is the more appropriate choice and will lead the doctor to either:
- clearly document the objective clinical appropriateness in the medical records to leave no doubt that function and pain control have been maximized while best practices were followed, or
- pursue a gradual, strategic and appropriate tapering process to the lowest possible (or no) dose while sharpening coping skills and equipping with non-pharma management tools that reduces risk and increases benefit.
In both cases, it’s the payer’s responsibility to reward best practices by paying for the necessary services, however atypical they might be. And to hold accountable those that don’t follow best practices.
The pendulum swung too far in the mid-1990’s and created incalculable harm. We can’t afford for the pendulum to swing too far in the other direction. It’s easy to say all or none. The right answer is always more nuanced. Appropriate, not zero, opioids should be the goal. For everyone.
Mark Pew, The RxProfessor, Educator and Agitator