Opioid Bias Hurts Pain Patients
As I travel around the country, two issues keep surfacing: 1) the abrupt cutting off of legitimate patients from opioids, producing withdrawal and re-emergence of their pain; and 2) the bias against the use of opioids by states, even for legitimate pain patients.
Let’s examine the first scenario. I get the opportunity to speak on electromagnetic therapy in Veterans Affairs (VA) hospitals across the country a few days each month. Last week, I heard a story about a recently returned veteran who was injured in the Afghanistan war. His pain has been controlled on 4 hydrocodone/acetaminophen (7.5 mg long-acting) a day. He has a wife, 2 children, and a good job. His work duties, however, interfered with his regular VA appointment. When he missed his appointment, the clinic refused to refill his opioid prescription and wouldn’t give him another appointment for 3 months.
With no opioids, the young veteran went into severe withdrawal—with fever, chills, vomiting, diarrhea, hypertension, profuse sweating, and re-emergence of pain—and was unable to get out of bed. Fortunately, the patient’s family prevailed on the hospital administration to put pressure on the clinic’s physician to fill his prescription. The tragedy here lies in a lack of understanding about the suffering and hazards of abruptly stopping opioids. Is this any way to reward a young man who has served our country and been injured in the process?
As all pain practitioners know, abruptly stopping opioids is never a good idea. Even if the patient is on a relatively low dose, withdrawal symptoms can be very unpleasant. And as we all know, completely unnecessary if the patient is allowed to taper off medications.
Another growing concern is the inability of patients to fill their opioid prescriptions—that in extreme cases—leads to abrupt stoppage of medications. Last month at the American Academy of Pain Medicine meeting in Phoenix, the growing shortage of opioids in pharmacies across the country was a topic that repeatedly surfaced. Patients with severe pain conditions like autoimmune disorders, cancer, and centralized pain, have been forced to shop around to many pharmacies in their areas to fill their opioid prescriptions.1 Many patients in the process have reportedly suffered with re-emergent pain and withdrawal symptoms. This begs a simple question. Have pharmaceutical suppliers become so uncaring and calloused that they no longer care for the welfare and comfort of our citizens who suffer daily with severe pain and infirmity?
While the media focus on people who overdose on opioids, and the handful of criminal doctors and pharmacies that prescribe and supply them, many government bureaucrats forget that the vast majority of prescriptions for opioids are legitimate. Hardly mentioned in all the news stories that bash opioids is how much suffering opioids relieve, and that the vast majority of physicians safely prescribe opioids and provide humane care.
State Bias Against Opioids
My biggest gripe these days are states that have restricted and deprived their residents of opioids—for example, Washington, Colorado, Massachusetts, and Florida. [For a state-by-state guide to opioids prescribing, see http://www.medscape.com/resource/pain/opioid-policies] Some states even brag that they have cut down on opioid prescribing. Maybe so, but they neglect to tell you that some of their most suffering, legitimate patients are crossing state lines like fugitives to obtain medical care. In California where I dwell and practice, I sometimes feel like we’re the proverbial dumping ground for states who don’t want to face up to their responsibility and care for their residents who suffer with intractable pain. I would like to think that the opioid-depriving states and physicians are just ignorant and don’t realize that every medical condition, including pain, has its outliers who we physicians can’t just “kick down the road.” I’m afraid, however, that patients with intractable pain pose an expense, time, and emotional need that some states and practitioners can’t tolerate.
My View on Opioids
To again set the record straight, let me, as I’ve done many times in the past, restate my editorial view on opioids:
- First, opioids are a last resort—the last step on the therapeutic ladder.2 Opioids should not be chronically prescribed until a plethora of non-opioid therapies have been tried and failed. This applies to cancer and non-cancer conditions.
- Second, pain is not only the greatest suffering of human kind, it is a disease process in and of itself. It causes hypertension, tachycardia, hyperlipidemias, osteoporosis, loss of brain matter, depression, and endocrine dysfunction among other manifestations.3-9 Whatever it takes to control pain must be exercised by caring physicians, even opioids as a last resort. Let’s again state the obvious—physician may be hesitant to prescribe opioids because of Drug Enforcement Agency (DEA) scrutiny and the risk of abuse, misuse or diversion. Dosages should also be kept as low as possible but not restricted if severe pain can’t be controlled.
- Third, opioid withdrawal can be a serious, suffering state in pain patients. While opioid withdrawal in an addict is rarely life threatening, such is not the case in a pain patient. When opioid withdrawal begins, pain may flare with its attendant hypertension, tachycardia, vasoconstriction, and other manifestations of a hyper-aroused autonomic nervous system. Pain patients with underlying cardiovascular and neurologic disorders can even perish if suddenly deprived of opioids.10
Has our society collectively decided that they want suffering, dread, and misery to befall our veterans and disease-ridden brothers and sisters? I don’t think so. It certainly appears, however, that a few persons in the medical community, government, and media no longer care about pain and suffering. It’s time to stand up and point out the inhumanity of suddenly stopping opioids.