restrictions on hydrocodone … do not appear derived from evidence-based guidelines and probably won’t do much to reduce the vast majority of inappropriate prescribing, although they may slightly curtail physicians that run pill mills and may also help with diversion
Despite the fact that opioid monotherapy is sub-optimal care, it happens all the time. I’m not sure how the FDA restrictions will help a doctor, who has less than 15 minutes and may not fully understand the multidisciplinary approach required to address chronic pain, delve into anxiety, depression, physical therapy, cognitive behavioral therapy, weight loss, pacing, adjuvant medications, nerve blocks, dietary modifications, and the appropriate use of opioids (just to name a few therapies).
How do we approach non compliance in chronic pain when opioids are on the table? …what if a patient is less than compliant with physical therapy or flat-out refuses yet shows up on time for her opioid prescriptions?
Keep in mind that PT is just an example, the main point being that all adjunct therapies are rejected and only opiates are wanted. However, this could be due to having already tried many other therapies over the years and found them unsuccessful or even dangerous. (Many EDS patients are sent to physical therapy for “exercise” that further damages their delicate connective tissues.)
Patients are even coerced into submitting to dangerous invasive procedures, like spinal epidurals, in order to prove them ineffective before they are allowed pain relief from opiates (see Hidden Danger of Intraspinal Steroid Injections). If patients decline this risky and ineffective procedure for fear of paralysis or arachnoiditis, they are accused of faking their pain to get opiates.
How will the FDA restrictions guide clinicians in these scenarios?
In almost every single health plan in the United States it is easier to get an MRI and back surgery than it is to get physical therapy. FDA restrictions will not solve this problem.
There are only a few generics for the medications that can actually treat chronic pain, so most of these drugs are very expensive. Many opioids are as cheap as M & Ms. A few extra hoops for hydrocodone won’t solve this issue.
And finally, we practice medicine in a world where some chronic pain conditions respond suboptimally to evidence-based therapies and appropriate, responsible opioid prescribing may be a necessary component.
Some doctors may refuse to start opioids (good for some patients and bad for others), but many doctors will probably just leave written prescriptions with their receptionists for their patients to pick up. In summary, the American problem with opioids and chronic pain will remain unchanged.