Confessions from an Opioid Prescriber

I applaud the recently released CDC guidelines on chronic opioid prescribing (available at: http://www.cdc.gov/drugoverdose/prescribing/providers.html). In the last few days alone, these guidelines have encouraged me in the care that I was already prescribing and reaffirmed my experience along the slippery slope of chronic-pain management.

At some point, physicians were told that we were ignoring the pain needs of our patients. As professionals programmed to seek cure for our patients, the response was a prescribing frenzy of arguably the most dangerous class of legal medications in an effort to treat a condition for which there was no diagnostic testing or reliable way to measure success.

I am as guilty as my colleagues in looking to opioids to help solve the problem of chronic pain. Unfortunately, the systematic use of opioids for long-term treatment of chronic pain seemingly has caused more harm than good as we now wrestle with an epidemic of prescription drug abuse. Further adding insult to injury, opioids are probably not all that great for chronic pain anyway. I know in my own patients that I have rarely seen substantial, long-term improvement in any measure other than subjective pain improvement, which is why I have practically no patients left on these medications in my practice.

The fact remains that many, many patients truly suffer with chronic pain and face a daily struggle to perform basic functions of living. The love affair we’ve had, as a nation, with these potent medications has distracted us from some of the very basic principles of good pain management. In the most egregious examples, physicians have run pill factories or sought highly lucrative pain practices that failed to actually help relieve suffering. 

One of my favorite patient-oriented presentations on pain (https://www.youtube.com/watch?v=B2SI-gmpDUU) emphasizes the very unexciting treatment modalities of nutrition, sleep, stress management, and overall healthy living. While not technologically-advanced treatment, these are likely to be more potent in the ability to improve function than any combination of powerful opioids marketed today.

While, opioids appear easy, quick, and effective, they have proven to be the opposite. They do not appear terribly effective -certainly born out in my own practice. Most patients on chronic opioids do not report significant pain reduction over time or improved ability to work, engage in relationships, or function well. The challenges patients experience obtaining these medications and the labels they receive when requesting them complicate, in many cases, their overall care and relationship with the medical community.

With this evidence-based, expert level acknowledgment of what my own practice has taught me for the last few years, I feel increased confidence that when I tell my patients an opioid is not the answer, I will be supported by my colleagues and the medical community. I am hopeful that beyond just stopping a high-risk, low-benefit treatment for a serious medical issue, these guidelines and the conversation they bring about will prompt us to continue the search for effective and rational treatment of chronic pain.