Professionals Respond: Stop Stigmatizing Opioids

Readers Respond: Stop Stigmatizing Opioids – Charles E. Argoff, MD – July 05, 2018

This article shows that at least some medical professionals are wiser than public opinion.

They understand that opioids can be effective and safe tools to control intractable pain.

I want to thank all of you who commented over the past several months on my earlier Medscape commentary from December 15, 2017, “When Are Opioids the Right Treatment?” I’d like to discuss some of these comments today.  

A physical medicine and rehabilitation specialist related his clinical experience following injured workers longitudinally for years on chronic, relatively stable doses of opioids.

He noted that many of these workers have been able to show clinically meaningful improvements in function, which he described and defined as being able to work. This specialist also published his own 2017 article in Journal of Occupational and Environmental Medicine, “Work Enabling Opioid Management“.

The importance of childhood trauma as a contributing factor to substance use disorder was also noted by a number of responders. One response pointed to studies that noted the high prevalence of significant mental health issues in more than 60% of a population of people prescribed opioid therapy for pain.

A comment from a healthcare provider who has been treated him- or herself for chronic pain emphasized,

Everyone doesn’t get super high from the drugs considered addictive. I need help not to avoid addiction, but to be able to function as well as possible.

Another healthcare provider noted,

My first thought is that this article is totally irrelevant. What? A physician suggesting that other physicians make clinical decisions about medical therapy? How many of us have been handed a letter from our patient’s insurer, telling them that their doctor prescribed the wrong medication? Of course, they never mention their idea of what the right medicine is.”

A general practitioner noted,

“Dependence is the rule, addiction is the exception.”

A healthcare administrator noted,

“Some of us are in situations where moderate to high levels of pain will be with us forever. Opioid therapy provides us a way to actually live. I am sorry so many have abused this.”

Seeking Open-Minded Providers

Another comment I’d like to share:

I’m very clear that we/I have many patients who a much higher quality of life that greatly contributes to their use of opioid therapy.

This occurred because some kind, brave, open-minded provider was willing to legally prescribe appropriate dosage of a variety of controlled substances, so their pain can be controlled when needed.

The patients I’m speaking of are a subset of people who have been honest and determined and are indeed dependent, but not addicted to the drugs.

I know there are many reading this who believe I’m either naive, stupid, or crazy, but I appreciate the input from any of you who have seen these patients yourself.”

Fighting Against Sensationalism

Here’s a response from a healthcare provider who was treated with chronic opioid therapy:

“Reading this article and the comments posted, it has become horribly apparent that healthcare professionals harbor opinions regarding the use of opioid medications for chronic non-cancer pain management which are grossly misrepresented by misinformation, distortion of evidence-based research, political influence, and even mainstream media sensationalism-style reporting, which together has deteriorated to such an extent that it is beyond belief.”

This person also goes on to state,

“A person should review all available information that is opposing the arrogantly forgotten patient. Opiates are great and should definitively be given to prevent suffering from pain, not for pain.”

Another comment:

Every possible treatment that can be used to help curb the pain should be found and used to prevent suffering and the need for opiates, non-opiates, psychology, physical therapy, injections, surgery, and yes, opioids, which are part of any pain specialist’s armamentarium, or they shouldn’t be practicing pain management.”

Monitoring Closely to Avoid Addiction

From a family practitioner:

“I have treated any patients over the last 10 to 12 years with chronic opiates. The majority seem to be helped with this therapy.

Many would lead a life of despair without these meds.

Unfortunately, many patients with failed spinal surgeries are left in severe pain and don’t respond to injections or spinal cord stimulation, et cetera.

As long as they show no signs of impairment, or drug-seeking behaviour, why stop an effective treatment?

Close monitoring, though, is necessary to identify the occasional drug seeker, and urine toxicology is helpful. I believe our job is to relieve suffering and increase daily functioning. I believe opioids should be used, but we need to understand what we are treating. We should treat all with lots of skill and empathy but also with our eyes wide open for problems.”

Myriad Opinions on a Complicated Issue

I want to comment on the fact that the providers who prescribe opioids have been under tremendous pressure to not prescribe opiates.

All of the comments here are interesting, because I think they reflect the disconnect between wanting to be patient-centered, treating each patient individually, noting that opioids can be the better choice, while also reflecting the outside pressure to not use opioids, even the understandable cynicism at times. I feel for prescribers and also for patients, being one myself.

from a nurse practitioner:

“I spent 13 years in rheumatology. I had many patients dependant on opioids, benzos, perhaps 5% truly addicted. I had to be able to demonstrate that the drugs were providing some relief, and that the benefit-risk ratio for each individual patient appeared to be acceptable to both of us.

I have seen far more problems with NSAIDs than with opiates.

From an emergency doctor provider:

“Bear in mind that NSAIDs are far from benign drugs, especially in the elderly. We should be hesitant to ever use drugs like ibuprofen in the elderly because renal, cardiovascular, GI morbidity and mortality make this class of medicine frankly dangerous in the elderly. Opiates certainly have risks, but they’re a bit more predictable and often the more benign choice, versus NSAIDs, when managed properly.”

Finally, from a healthcare provider:

Thank you for a sane article about opioids. No statements that ibuprofen works as well as opioids or back pain implied for everyone. No equating drug dependence needing a larger dose for the same effect with addiction, no recommended zero opioid prescribing policy.

Think of all the foolish zero tolerance policies now in our society, and the trouble and confusion they have caused, nor should there have ever been a one-size-fits-all of treating every patient with pain by prescribing opioids, especially as a first-line, to-be-continued treatment.”

In summary, I hope these comments further epitomize and suggest how complicated opioid therapy is. But what I am struck by is how much these comments point to identifying that subset of individuals for whom these medications are successful.

By no means is this discussion over. I hope that you are interested in and recognize the diversity of opinion, but the underlying theme is that opioids can be prescribed successfully for certain people with chronic pain.

Author: Dr Charles Argoff, professor of neurology at Albany Medical College, and director of the Comprehensive Pain Center at Albany Medical Center in Albany, New York

 

1 thought on “Professionals Respond: Stop Stigmatizing Opioids

  1. canarensis

    Another great piece. It is so heartening to see that there really are medical professionals who back the reasonable use of opioids. I’m enough of a cynic to think it won’t affect the hysteria, but it’s good to see nonetheless.

    I found it interesting but not in the least surprising that a some of those quoted were themselves victims of chronic pain…a perfect reflection of the fact that for the most part, only those who experience it can truly understand it. It’s sorta like the different understanding of what combat is truly like from those who’ve been in it versus civilians whose closest brush is in movies. Tho really, I think enough has been written & filmed about the horrors of war that civilians can have a vague idea of it (though not nearly the reality).

    Actually I think the gulf is wider in a way –pain “civilians” have all experienced some sort of pain so they know –they think they know– what it’s like; ouch then over, what’s the big deal, “take a couple aspirin & quit whining.” The pervasive macho influence sure doesn’t help the empathy process.

    As to the study that noted the “…prevalence of significant mental health issues in more than 60% of a population of people prescribed opioid therapy for pain.” I wonder if they’re counting depression…seems to me that anyone suffering chronic pain who ISN’T depressed would be in the great minority. It’s hard not to be depressed when your life revolves around horrendous pain and the resulting disabilities & separations from life, work, family, etc. But I think this simple idea, which doesn’t imply cause/effect either way, would be/is pounced on eagerly by anti-opioid zealots as “proof” that pain patients are addle-brained addictive types anyway.

    I’ve got my 2nd appointment in 3 months with my new doc coming up, & am queasy with anxiety. All the hypothetical conversations I hold with him in my head are like dancing through minefields. Any statement can be twisted as proof that I’m not in “real” pain (like going to an ER with advanced dehydration & asking for fluids, & having them keep loudly insisting that what I’m REALLY asking for is pain medication, slyly asking for them by not asking for them…& not even getting the fluids. You can not win). He seemed reasonable the first time, but after 15 years with my previous doc (who suffered chronic pain herself), it’s hard to imagine a doc not behaving like all the other ones did. And the state wasn’t about to declare a complete ban on opioid therapy then, without exception, so I guess it doesn’t matter what the doc thinks.

    Anyway, thank you for another excellent post.

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