This is one of the most thoughtful and objective pieces I’ve read on the topic of opioids. I don’t walk in your shoes, and it’s not my place to judge anyone. As a healthcare provider, my main objective is to address your health concerns with the best treatment and information I have at my disposal, not to preach a hole in your ear.
Source article: https://www.medscape.com/viewarticle/898663
This is 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.
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.”
Another person commented that while so much attention has been placed on the more chronic use of opioids, many people who experience chronic or chronic intermittent pain use opioid therapy not daily, but quite successfully intermittently. Yet even in these circumstances these individuals now have difficulty accessing treatment.
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. This study estimated that 50% of the opioid prescriptions written in the United States go to 18.7% of Americans who experience significant mental illness.
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 am elated to see a discussion opened on this topic and I’m rather surprised by the number of high-quality comments and discussion it produced. 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, and/or their symptoms of withdrawal are abated or prevented, meaning that they are not in acutely severe pain but need the med for the prevention of the withdrawal symptoms that will cripple some if the med is not ingested. 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.”
Another interesting perspective came in a response to this comment:
“Thank you for the eloquent response and I agree that this thread has generated some of the best responses on this topic. Your example illustrates that the use of opioids is not black or white, good or bad treatment decision. Every patient is unique and responds to each treatment, including opioids, differently. Further, each opioid is unique and produces a different response in each individual patient.”
Here’s a response regarding concern about diversion:
“Since I graduated from internal medicine residency 3 years ago, I’ve been struck by the complexity of this matter, especially that I believe in training, residents are not exposed or trained enough on narcotics and pain management. When one graduates and starts working, especially as a primary care physician, this person would be overwhelmed with the burden of narcotic prescription in pain patients, knowing that most of these patients are inherited from leaving providers which makes it even more complicated. My biggest issue with this is that narcotics diversion may occur, and a lot of the time I feel like I’m the detective who is trying to figure out who is diverting and who is not.”
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.”
“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.”
There was a comment in reaction to that which said that opioids should be used in the context of an overall multimodal treatment program and how that’s not always being done.
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.
Another comment that speaks to this comes from a psychologist:
“I am certain that my anxiety about needing this medication to treat my restless leg syndrome made me seem like a drug seeker. The thought, however, of surviving without any control of my restless leg syndrome was a truly terrible worry.”
Here’s one 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 and also outlining the risk of so many other medical treatments, both interventional and noninterventional, that we consider for our patients with chronic pain.
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. I hope you have found this useful and instructive. I’m Dr Charles Argoff.