Controlling the Swing of the Opioid Pendulum

Controlling the Swing of the Opioid Pendulum | NEJM – Feb 2018

Mr. P. is a 34-year-old man who sees his primary care physician regularly for chronic spine pain. Several years ago, he had a motorcycle accident that left him with a ruptured spleen, a shattered pelvis, and multiple thoracic vertebral fractures.

His daily pain regimen consisted of 3600 mg of gabapentin, 60 mg of baclofen, 120 mg of oxycodone IR (a 180-mg morphine-equivalent dose), and nonsteroidal antiinflammatory drugs as needed.

Mr. P.’s condition had been stable on this regimen for 2 years. His prescription-drug monitoring reports and urine toxicology screens were pristine.  

Unfortunately, his primary care physician announced that her practice had adopted a no-opioid policy. Mr. P. was given a prescription for a month’s worth of oxycodone and advised to find another prescriber in the future.

Not unexpectedly, six other physicians refused to prescribe him opioids, and he ended up in our pain clinic, sobbing in the exam room, terrified that he’d end up “back in my old life” if he had to buy his pain medications on the street.

In the past year, our university-based interdisciplinary pain clinic has seen a flood of cases like Mr. P.’s.

The increase in opioid-related mortality fueled by injudicious prescribing and increasing illicit use of both prescription and illegal opioids has led some clinicians to simplify their lives by discontinuing prescribing of opioid analgesics.

The fallout is a growing pool of patients who are forced to navigate their transition off prescribed opioids, often with little or no assistance or guidance, with the potential for disastrous results.

Well before the opioid crisis was recognized and attention was directed to opioid-related deaths, clinicians cited issues related to opioids as a principal reason why they didn’t enjoy caring for patients with chronic pain.

Now, many physicians and advanced care practitioners (nurse practitioners and physician assistants) have decided that the risk associated with prescribing opioids is too high.

Some clinics, particularly in locations with high rates of opioid misuse, have established policies of not prescribing opioids at all.

The reasons for such policies are complex. Most clinicians have inadequate training in the modern treatment of chronic pain and had learned that opioids were safe and effective for all forms of chronic pain.

With increasing legislation and scrutiny by medical boards, pharmacy boards, and federal agencies such as the Drug Enforcement Administration (DEA), many physicians believe that the risk of incurring sanctions is too high for them to continue prescribing opioids.

Furthermore, it’s becoming more difficult for physicians to prescribe these drugs.

Increasingly, prescription-drug plans are instituting complicated and confusing opioid-prescribing rules.

Often, limits are placed on dosage forms, quantities, or both without any evidence that such restrictions will ameliorate opioid overuse and misuse.

Apparently, the anti-opioid crusaders don’t feel they need evidence because they are on a mission from a “higher power”. If they actually looked and counted anything besides opioid milligrams and overdoses, like suicides due to pain, they would see the obvious:

Prescribed milligrams of medicinal opioids
have been and are going down
while overdoses from illicit street opioids
are rocketing upward

Perhaps they believe they above such mundane concerns as providing real-world proof of success because the real-world data clearly shows the diverging trends of overdose numbers and milligrams prescribed.

The anti-opioid crusaders seem to believe all opioid users are addicts and all addicts need 12-step recovery directed by a “higher power” (and paid for by insurance companies and taxpayers).

Navigating these rules is time consuming for both clinicians and pharmacists, who are increasingly dissatisfied with their work and unenthusiastic about caring for patients taking these medications.

An even more unsettling phenomenon is drug-coverage plans’ discouragement of the use of safer opioids, such as buccal buprenorphine, in favor of less expensive but more dangerous alternatives such as morphine.

In our opinion, however, the most important contributor to a desire to stop prescribing opioids is the effect of opioid prescribing on clinicians’ emotional well-being.

We worry about the potential unintended consequences of these medications even if they’re used appropriately. More immediately, it’s difficult to walk into an exam room knowing that we have to significantly reduce or stop a patient’s opioid treatment — and then deal with the lengthy, emotional, possibly confrontational encounter that typically ensues.

I’m appalled that they didn’t mention the complete lack of ethics when forcing someone to suffer preventable pain.

an enormous number of patients are currently using prescription opioids. Many of them will need to have their doses reduced or be weaned off completely, but many cannot achieve adequate pain control without their current doses.

All these patients deserve compassionate and skilled pain management.

I notice it’s not mentioned thatcompassionate and skilled pain management” includes the opioids they are taking away.

We fear that an injudicious approach involving blanket refusals to prescribe opioids and adoption of unreasonable prescribing and dispensing regulations will increase patient suffering.

Furthermore, the worst-case scenario[?] is for patients to obtain prescription opioids illegally and eventually transition to more dangerous drugs, such as heroin.

No, that’s still far from the worst, which is happening right now:

patients are committing suicide
because without opioid pain medication,
their pain is literally not tolerable.

Most patients with chronic pain are cared for by primary care clinicians; others are treated by specialists whose primary training is not in chronic pain. There are too few U.S. pain clinics to care for all these patients, and referring them simply for opioid stewardship is both inappropriate and unrealistic.

Yet, this is *exactly* what’s being done by the noble profession of medicine. Patients are given 30 more days of pain relief and kicked out, referred to “other” doctors, for whom the waitlist runs to years and who may not even exist (be accessible).

But some key steps can be taken.

First, all clinicians can improve their knowledge about evaluating and treating chronic pain. We believe the opioid crisis is largely a crisis of inadequate treatment of chronic pain.

Increasingly, educational opportunities are becoming available through professional organizations such as the American College of Physicians and the American Academy of Family Medicine.

In addition, Project ECHO ( offers interactive, case-based telementoring clinics throughout the United States and Canada that provide clinicians the opportunity to present cases on a video platform and learn pain- and opioid-management skills from peers and experts in real time

Second, clinicians can consider transitioning patients from risky opioid regimens to safer buprenorphine treatment for chronic pain. We believe that every effort must be made to reduce the morphine-equivalent dose of opioid analgesics to the safest dose achievable.

Buprenorphine is a partial agonist–antagonist of the mu receptor with excellent pain-relieving properties and a much safer overdose profile. Many studies show that patients taking high-dose mu-receptor agonists such as morphine or oxycodone can be successfully transitioned to this medication.

Buprenorphine is only a “partial agonist” and thus only partially relieves pain. Of course, the anti-opioid crusaders don’t care how much pain relief it provides, only that it’s “safer”.

Third, clinicians can adopt risk-mitigation strategies for patients taking opioids. OUD is a common, potentially devastating condition that may co-occur with other medical conditions involving chronic pain.

Actually, OUD is NOT common (less than 10%), but they keep saying this and no one in the media contradicts or even questions it. 

Risk-mitigation strategies such as periodic urine drug screening, scrutiny of prescription-monitoring reports, identification of aberrant behaviors, and patient education in safe use and storage of opioid medications are of paramount importance for all patients taking opioid analgesics

Opioid analgesics are an important part of our therapeutic armamentarium, but they have serious consequences when used improperly.

As the pendulum swings from liberal opioid prescribing to a more rational, measured, and safer approach, we can strive to ensure that it doesn’t swing too far, leaving patients suffering as the result of injudicious policies.

It’s too late – the pendulum has already swung far into prohibition territory.

Many patients have already taken their lives because their only effective pain relief was unilaterally and deliberately taken away by a “medical provider”. (I just can’t bring myself to call someone who is literally torturing their clients a “doctor”.)

Original article:Controlling the Swing of the Opioid Pendulum

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