‘I PRESCRIBE OPIOIDS. WE SHOULDN’T TREAT EVERYONE LIKE AN ADDICT’
A pain doctor cautions against “a blanket no” on opioids for all patients: “The pendulum has swung too far.” by Dr. Linda Bluestein
One of the very first patients I treated
after opening my pain practice tested positive for heroin. It was 2017 and I had just started a clinic focusing on the integrative management of pain patients after over 20 years of practicing as a medical doctor and anesthesiologist.
This patient had traveled to me from several hours away—something that can reflect poorly on a prescriber—but she had a diagnosis of Ehlers-danlos Syndrome, a painful connective tissue disorder, and an existing opioid prescription. She was in her thirties and had various comorbidities and pains in different parts of her body.
Back then I thought I knew a lot, but I had only just begun. I believe that if you’re doing things properly as a pain doctor, you are continuing to learn throughout your career through evidence-informed practice. It’s not just a randomized controlled trial, it’s looking at so many other types of evidence, as I should have done in the case of this patient.
I took over her prescription and gave her a small number of pills, but days after collecting her urine sample the results came back positive for heroin. Right then and there, I knew this was a whole other ballgame.
I immediately started reaching out to her, using various forms of communication to try to contact her. She never responded to anything, so in early 2018 I ended up firing her as a patient.
I know that some people do resort to street drugs because they can’t get their opioid prescription, and withdrawal is a horrible thing, but testing positive for heroin is a huge red flag. We needed to work with her psychiatrist to assess her addiction risk. The whole thing was an awful experience—i felt terrible, but ultimately, I wouldn’t be able to take care of her.
A PAIN SPECIALIST’S PERSPECTIVE
I finished my residency in 1994, and for around two years worked in a small hospital’s pain clinic, focusing mainly on procedures. While medically managing those patients was a very minor part of my work at the time, my recollection of that period is that we were not typically treating chronic pain with opioids.
I spent quite a few years practicing in the operating room before I opened my own clinic, which was a very steep learning curve. I also have Ehlers-danlos Syndrome, which I was still trying to manage at the time, though I do not view myself as a chronic pain patient.
I have never taken any opioids on any chronic basis—in fact, I’ve been afraid of them since day one as an anesthesiologist, because within the profession there are extremely high rates of addiction.
Particularly in the early days of my practice, things were not as closely monitored as they are now, and I believe that maybe even I was a little more liberal with prescribing opioids.
I had many patients come to me to take over their opioid prescribing, but with every single one I would have to explain that, as I was a solo provider, my prescriptions should act as a bridge; I should not be their main source of their medication.
However, for many of my patients nowadays, finding alternatives has become really difficult. Their mobility is often limited, and they’re in so much pain, it’s hard for them to even get to appointments with other pain physicians.
While I understand the prescription of opioids has been quite the process over the past few decades, I feel the pendulum has swung too far. The opioid crisis is so very real; I know people on every side of this equation. I know people whose children have died due to opioid overdoses, but I don’t feel we are individualizing patient care.
In my experience, in the last five years patients in acute situations or who have undergone surgery are not even getting a small amount of a stronger medication, as they may have before the opioid crisis.
I have seen physicians receive calls from their patients in terrible pain, who had undergone surgery that day, but were given nothing other than paracetamol [also known as acetaminophen] and ibuprofen—despite some studies showing a patient is at higher risk of chronic pain if postoperative pain is poorly controlled.
I don’t prescribe opioids very often at all, and believe that for most
patients with chronic pain, they are not the right treatment. However, for the small subset for whom opioids are the right treatment, it’s very difficult to get them. I feel like we’ve put a blanket “no” on opioids for everyone.
It’s complicated because nobody can tell you how much pain you’re in. It’s a subjective experience, and it doesn’t always correlate with the findings on imaging or laboratory testing, which makes it very hard for us to assess.
EXHAUSTING OTHER OPTIONS
I do not believe the degree of pain that someone is experiencing is an indicator of whether they should have an opioid prescription. Rather, we should ask: Have other things been tried? What’s this person’s status like?
For example, the case of an older person going through palliative care is very different than that of patients who are 15-20 years old. Every single time I write a prescription I think: “What does this look like long term? Is this something that’s going to be safe for this person to take on a long-term basis?”
I’ve had patients as young as 15 years old come to me and on their first visit ask me to fill out their disability paperwork. I feel terrible that these people are suffering, but they come to me for help, and I can’t
“NOBODY CAN TELL YOU HOW MUCH PAIN YOU’RE IN. IT’S A SUBJECTIVE EXPERIENCE.”
name a single instance in which someone has come to me and I didn’t have ideas of something else to try. For me, the goal is not to have people on disability, sitting at home and taking opioids, but to improve their quality of life and give them quality years, especially with my younger patients.
As a pain management physician, you have to play detective, because if a patient is suffering from addiction or is at high risk of addiction then somebody like me should absolutely not be managing their opioids. They need to be in a setting where they receive comprehensive care. Every time I write a prescription, it’s going under my medical license, my DEA certification, and all the time and work that went into that. I do feel there are a very small number of patients who have made it difficult for the people who are legitimately in pain, and for whom opioids are the best option.
Addiction is a very serious problem, but I don’t think we should be treating everyone like they’re an addict. In fact, some people are at extremely low risk of becoming addicted to opioids or any other medication—we shouldn’t be lumping everyone together.
I think the phrase “war on opioids” is horrible. I understand the sentiment, and that often in our culture we use these catchphrases to get a message across, but in my eyes it’s not benefiting anyone.
I believe we have so many processes and programs in place to prescribe opioids that are not serving our patients. In my opinion, we need to take time to really understand patients’ situations, not race through every person—part of which I believe is down to insurance and a third-party payer system which has created an absolute nightmare for quality care.
TREATING PATIENTS AS INDIVIDUALS
When patients have chronic pain, they need to know we’re there for them. If a person is in pain and knows that you don’t believe them, that makes them feel horrible and can actually increase their levels of pain.
When I was in pain, I was very aware of the fact that when I was under more stress, I had more pain. So we as doctors need to be alleviating people’s stress, not creating more.
While I do not believe opioids are the best option in most cases of chronic pain, sometimes they are. And when it is, that person should be able to get that prescription without guilt and these barriers that are so incredibly onerous.
Many of these patients have difficulty accomplishing a lot of everyday tasks and even getting to appointments. We need to balance safety and patient care, not use one brush stroke for everyone.
meaning their prescriptions provide them with opioids for at least several months, and often many years. According to NIDA, these patients are considered “dependent” on opioids, meaning they experience withdrawal symptoms if they stop or cut back. But they generally aren’t considered “addicted,” which NIDA defines as compulsive drug-seeking and as continuing on with the drugs in spite of the large risk of harm.
Chronic prescription opioid users, in fact, tend to use the drug relatively safely. The bigger risk comes in forcing them to cut way back or stop. Still, that is exactly what has been happening across the country in recent years. One large study found that reducing dosages increased patients’ risk of overdose by more than 25 percent and of being hospitalized for a mental health crisis by about 75 percent. A second large study found that stopping their medications altogether made them about four times more likely
to die by suicide. The studies weren’t designed to determine why forced tapering or cutoff led to these grim outcomes. But to Kate Nicholson, an attorney who founded the nonprofit National Pain Advocacy Center, which does not accept industry funding, the implications are clear. “Forced tapering is highly destabilizing,” she says. “It’s dangerous.” Even the authors of the 2016 CDC guidelines that recommended the cutbacks warned in 2019 in the New England Journal of Medicine that the results appeared to be causing “serious harm” to patients.
In response to the growing recognition of the risk to patients of cutbacks, the CDC revised its 2016 guidelines in 2019, easing its call for restrictions and warning of caution in reducing or stopping the opioid medication of chronic patients. That call for caution has largely been ignored. Reports in the media decrying the supposedly wanton and deadly addicting of millions of patients by negligent doctors acting under the influence of puppet-master pharma companies have persisted. (New York Times: “How the Sacklers Got Away With It;” Reuters: “‘You got rich off our dead bodies’”; Fox News: “Overdoses continue to fuel sales for the Sacklers”). The finger-pointing encouraged state governments, courts, insurers, hospitals and doctors themselves to codify the cutbacks into regulation and standard practice.
In 2019 doctors in Wyoming and Alabama were sentenced to prison—25 years in one case—for prescribing opioids under toughened laws in those states. Those sentences were reduced in 2022 by a federal appeals court in one case and overturned by the Supreme Court in another. But the warning to doctors about the risks of prescribing opioids was clear. “The changes have had a chilling effect on care,” says Nicholson. “It’s left doctors afraid to prescribe medications to people who have been on them for years.”
Worse, Nicholson adds, the crackdown has led insurance companies increasingly to refuse to pay for opioids. For less-affluent patients, it is simply another form of shutting off their access—or pushing them toward illegal opioids.
How to Cut Back
Where America needs to cut back on opioid prescriptions, agree experts, is in routinely prescribing dozens of pills for “acute” pain—that is, pain that remains severe for a relatively short period of time, as is often the case with patients who have surgery. For these patients, there may be no
In 2009, I was put on opioid pain management by my primary care physician. For the next 12 or so years I was getting along quite well. Sure, I had some days that I still hurt, but it was much better than without using the opioids. In April 2021, I was forced off of them because my doctor was threatened by the DEA for writing me my prescriptions. I received half-filled prescriptions and was told my doctor would have to call in the remainder. In two weeks, I was out. When I tried calling my doctor, he had his staff in the office tell me he can’t write anymore for you because he’ll lose his license. I am miserable every day. I went from an almost normal life to a life of sitting in a chair most days writing to all the alphabet agencies.
ROB MARX
great need for an extended prescription of opioids, or in many cases for any opioids at all. “It might help to prescribe a small number of pills to help them get over that initial hump of pain, and then give them ibuprofen,” says Kelly. “But we shouldn’t be prescribing 30 or 40 pills to patients who aren’t already taking opioids for chronic pain, which is what was happening in the past.”
While the cutbacks have left chronic pain patients struggling to keep their prescriptions, they haven’t stopped the routine prescribing of opioids for acute pain, says Kolodny, and that needs to change. He notes that the average number of opioid pills currently being prescribed for post-surgical pain is 20, while among all other countries with advanced health care systems the average is zero— even in the hospital, patients in most countries simply get NSAIDS. “It makes no sense that we do that,” he says. “For most cases of severe acute pain, such as surgery or kidney stones, Tylenol plus an NSAID probably gives better pain relief.” Yet even dentists still routinely prescribe opioids for an ordinary wisdom-tooth extraction, he notes, and studies show that one in eight patients who show up in emergency rooms with twisted ankles get opioids.
Unnecessary prescriptions for acute pain lead to addiction for some patients, but this is a tiny minority; a 2021 review study found the risk of addiction from prescription opioids was less than three percent, and that figure included chronic pain patients,
I am 36 years old. I have been experiencing chronic pain since I was 25. I have bulging discs and degenerative disc disease, plus a diagnosis of fibromyalgia. Every doctor has either told me because of my age they would never prescribe me anything for pain or that my pain is normal. I struggle to function every day of my life.
NICOLE YELLOVICH