Chronic Pain Patients – Collateral Damage in the War Against Opioids

America is in the grip of an opioid crisis that has been declared a public health emergency. Governments at federal and state levels have responded on two major fronts: diverting resources toward addiction treatment and passing laws regulating opioid prescriptions. On the treatment front, the opioid crisis has attracted so much attention that addiction treatment has rapidly ballooned into a $35 billion per year industry. As an addiction physician, the increased funding has been positive for me, although the lucrative nature of addiction treatment has also attracted bad actors and opened up much potential for abuse. However, this essay focuses on the damage caused by the other prong of the response to the opioid crisis.

Most of the attention on the current opioid crisis has focused upon those affected by addiction. The National Institute of Drug Abuse (NIDA), estimated 2.1 million Americans had an opioid use disorder. Contrast this number to CDC’s estimate of 50 million Americans (1 in 5 adults) living with chronic pain, of which 20 million have “high-impact chronic pain”, severe enough to frequently interfere with life/work activities. Such epidemiological data are quantitative measures of the scale of the problem but are mute about the qualitative impact at the level of individuals. Many people with chronic pain still live fairly normal lives even if they must surrender occupational or recreational opportunities. For some however, the pain is truly devastating and unrelenting, stripping them of the ability to make a living, robbing them of dignity, and destroying quality of life to the point of contemplating suicide. These patients represent the “collateral damage” of current efforts to curb the opioid epidemic.

Over the past five to ten years, governmental agencies such as the CDC and FDA have aggressively pressured physicians to reduce opioid prescriptions while state legislators introduced increasingly burdensome rules governing opioid prescriptions. Accounts circulated around medical communities of DEA raids on physicians, seizing records, arresting practitioners and closing down offices. Individually, each of these actions might be supported, but collectively, they struck fear in the hearts of physicians afraid of running afoul of regulations, losing their license, livelihood, or worse. The impact was not limited to the level of individual physicians. Group practices and even entire hospital systems developed restrictive policies on prescribing opioids. Many physicians no longer even have the option to prescribe opioids. Millions of legitimate pain patients who had never abused their medications, through no fault of their own, had their doses slashed dramatically without their consent, a procedure known as “forced taper”.

As a result of these pressures, opioid prescriptions plummeted in recent years. For example, West Virginia led the nation in per capita opioid prescriptions in 2011 as well as per capita fatal overdoses. Spurred by its infamy, the state decreased opioid prescribing 42% by 2017, the largest drop of any state in the union. Despite trailblazing success at cutting opioid scripts, West Virginia remained the state with the highest age-adjusted opioid death rates because drastically slashing opioid prescriptions only aided and abetted the illegal opioid market. The problem had spread way beyond prescription opioids. Illicit opioids rushed in to fill the demand created by forced scarcity of legally sourced opioids, with heroin taking off in 2010 and illicit fentanyl bursting onto the scene in 2013.

It is easy to blame drug addicts for the shift to illicit opioids. In truth, extra-legal sources of opioids became increasingly enticing for people reliant on opioids – both legitimate pain patients and drug abusers experience the same severity of opioid withdrawal. For pain patients, there are many paths to heroin/fentanyl. Desperate for relief and feeling abandoned by their doctors, with no light at the end of the tunnel, some pain patients begin with pills from relatives and friends until those sources run dry. Many of my patients recount how eventually pain pills got too expensive with heroin much cheaper and easier to get. As one opinion piece in a Tennessee paper put it, patients in severe pain put on forced taper only have three choices: suffer, suicide or turn to the street. Severely restricting opioid access likely fed the very crisis it sought to control.

The case of West Virginia clearly shows that restricting access to legal opioid prescriptions cannot and will not reverse the opioid crisis. Draconian limits on opioid prescriptions serve no useful purpose. Forced tapers expose us to the moral jeopardy of betraying the sacred trust our patients place in us as physicians with a duty to help those suffering. The very word, patient, derives from the Latin verb ‘pati’ – to suffer. Treating pain patients as collateral damage is morally unacceptable, even more so as casualties of a failed strategy. Of the two groups affected by the opioid crisis, addicts at least have access to treatment; pain patients do not.

I am an addiction physician, but I have been managing opioids for chronic pain much longer. It may seem incongruous for an addiction physician to be advocating for improved access to opioids for chronic pain patients. I see no inconsistencies because I believe it is possible to prescribe opioids safely, both for the patient and for the prescriber. Many medications used in other areas of medicine have potentially serious adverse reactions. These drugs can be used safely as long as we monitor for development of toxicity. Similarly, patients prescribed opioids can be monitored for development of opioid use disorder and drug interactions, allowing for early interventions.

 I have known of many physicians in my region who were ensnared in DEA raids or subjected to other penalties. Working in this arena, I knew of these physicians through patients who left their practices, reviewing medical records, PMDP, or other reports. In every case, the raids did not come as surprises to me. Invariably, there were reports of unethical behaviors, suspect prescribing patterns, poor charting, etc. I have had dealings with the DEA and in my experience, they are courteous and professional; they are not the bogeyman. They do not take action lightly or without just cause. They are definitely NOT trying to put ethical physicians out of business. Prescribing opioids is actually far less dangerous than practicing obstetrics or emergency medicine. Learn the laws in your state and follow them, learn to prescribe safely, and just be ethical. It is the right thing to do.