The assumption that opioids are safe and effective for chronic pain is being repeatedly and fundamentally called in into question by a steadily accumulating collection of new scientific data. Against this backdrop, it is no longer medically or legally sufficient for doctors to accept certain drug manufacturers’ theories that a patient who gets addicted to opioid painkillers has no one to blame but themselves or the doctor. Doctors must take note of these developments and make allies of the changing assumptions. This is the best way for prescribers to protect their patients and themselves, to practice good medicine, and to comply with the criminal laws of controlled substance prescribing.
The prescription drug crisis facing our country and other parts of the world today has its origins in a research study from the late 1980′s, conducted by a drug manufacturer which wanted to sell opioids for chronic pain. The study said, to most everyone’s surprise, that opioids were generally effective and safe when prescribed for chronic pain. This had never been said before, because nearly a century of medical experience had shown that for acute pain, on the one hand, and end of life cancer pain on the other, opioids were sometimes the only painkillers that worked — but for chronic pain, the evidence of addiction was high, and the evidence of effectiveness was low. The new research in the late 1980′s turned this conventional wisdom on its head. The FDA approved opioids for chronic pain, which led to mass marketing by drug manufacturers, new education and instruction for doctors and medical students, and patients’ being prescribed the drugs on an essentially permanent basis. It also lead to today’s epidemic (the CDC’s term) of opioid addiction, overdose and death. The present crisis has forced reexamination of the basic assumptions about safety and effectiveness of opioid painkillers, and the developments cannot be ignored.
Here is what some of the leading voices in the nation are saying:
-”Neuropathic pain [pain not from a specific injury or with a specific, identifiable cause] typically responds poorly to…opioid painkillers.” – Medical Board of California, 2014.
-”Prescription opioids can help with pain, but they will not take away all of your pain and they might not improve your functioning or quality of life.” -Intermountain Healthcare Group (Utah), 2015.
-”Long term benefits for Chronic Opioid Therapy have not been established.” -Physicians for Responsible Opioid Prescribing, 2015.
-”Long term daily opioid use of 90 days or more is no longer considered good clinical practice for non-cancer pain.” -Los Angeles County Prescription Drug Abuse Medical Task Force, 2015.
-”Uncertain Long Term Efficacy; Clear Evidence of Harm.” -Washington State Agency Medical Directors’ Group, 2015.
While new studies and new statements might not mean a doctor’s pain management practice has to shift 180 degrees or close to it immediately, it does mean that the landscape is shifting, and doctors have to shift with it. Put another way, if the science is changing, you have to change along with it, otherwise you’ll be doing the same old thing when the science says you maybe shouldn’t be. Sooner or later, law enforcement agencies like the DEA and your state’s medical board will figure things out, and will accuse you of clinging to the old medical way when you should have been embracing the new. If you as a prescriber have done nothing, or done too little, to show you know what’s going on and have responded appropriately in your decisions about prescribing — whether to prescribe, not just how much or for how long — you’ll be in trouble.
From this perspective, the changing assumptions about the safety and effectiveness of opioids for chronic pain are a doctor’s ally, not adversary. Keep up on the new data, get help learning the law, get good advice on whether you are complying with the criminal laws of controlled substance prescribing, and together with your scientific knowledge and the right legal advice, you’ll be doing all you can to practice the medicine you want to be able to practice, and taking the best care of your patients and yourself.