Have We Reached the Tipping Point When it Comes to Opioid Therapy?

Recently, I admitted a woman in her late forties to an inpatient psychiatric unit after she overdosed on oxycodone, hydrocodone, alprazolam, clonazepam, and several other uncontrolled medications for “spasms” and other somatic problems. When I declined to restart most of her medications that were responsible for her overdose, she became irate and demanded that I do so immediately, claiming she had “rights.” More importantly, she said, “If you don’t, there are at least 500 other physicians in this state who will, and I can always buy them off the street if I must.”

Her “in your face” attitude and perception that I was trying to “hold the line” for no purpose other than covering my own license brought home the grim reality that many Americans believe they have been “promised” opioid therapy, and that they should receive ridiculous combinations of opioids, muscle relaxants, and benzodiazepines from prescribers who are ignorant of the consequences of their actions and/or are too afraid to say “no.” Prescribers have reached a tipping point, a moment in time, where we have to step back and ask if treatment is worse than the problems treated.

I trained in the 1980s to be a pain specialist after completing my residencies in psychiatry and neurology. I learned to take patients off of opioids who did not have a terminal diagnosis and use multidisciplinary methods with the goal of functional restoration and rehabilitation. Over the next 10 years of practice, I watched the paradigm shift to favor prescribing opioids for all forms of pain based upon our successful management of cancer-related pain with adequate doses of opioids.

I started writing about steps practitioners would need to take to stay out of trouble with regulators due to opioid prescribing as early as 1998. I watched as data flipped from showing opioids were safe and relatively free of serious addiction risk to being more realistic and owning up to the risks associated with opioid therapy. I attended many Food and Drug Administration (FDA) hearings in 2009 and 2010 regarding the development of the current Risk Evaluation and Mitigation Strategies (REMS) for extended-release and long-acting, single-entity opioids. I even participated in an online training program to become a more thoughtful opioid prescriber.

Sadly, many general practitioners, family practitioners, internists, OB-GYNs, and other “frontline” practitioners either never received opioid REMS training, or just didn’t care how they prescribed because the bodies keep rolling into emergency rooms, hospital beds, psychiatric treatment programs, chemical dependency treatment programs, and other services.

While the peak of the opioid epidemic may now have been reached (according to some), we are not out of the woods. Every decision to start or continue opioid therapy must be careful, deliberate, and weigh benefit against risk, while keeping in mind that risk is not constant/static, but dynamic and evolves through time. Clearing someone for opioid therapy today has no absolute meaning for future treatment planning. Early detection of misuse and abuse is important; changing treatment is critical. If risk moves from low to high, time between visits and number of unit doses must reduce. This isn’t rocket science, this is common sense. When things don’t add up or make sense to you, it means your patient is not telling you all of the facts or you not being told the truth.

So, just how cynical and suspicious should we be if we want to have long careers in pain management? What treatment options are truly effective over time? How can emerging research and science help us to make better treatment decisions? Keep reading this website as we review a series of articles from leading pain publications.

B. Eliot Cole, MD, MPA, is a member of the Pain Management editorial advisory board. He has served in executive positions for several prominent pain management organizations and societies, including the American Society of Pain Educators and the American Academy of Pain Management. He has been a pain management fellow, clinician, educator, and advocate for nearly 30 years and has practiced in a variety of settings serving a wide range of patients.