The Opioid Crisis

This blog post is going to be a little bit of a departure from my normal topics of pain conditions/treatments. I feel strongly that pain management doctors like me, on the front lines, need to share our experiences and thoughts regarding the opioid crisis.

I was trained right on the cusp of the high dose opioid era and the current crisis. I remember in medical school, on the one day we spent on pain management (yes, you read that right), going through a very logical chart from the WHO that made pain management sound so simple: first start with a non-opioid pain medication for mild pain, then add a mild opioid/short acting for moderate pain and then a strong opioid/long acting for severe pain. Sure, we touched on the fact that opioids can have issues with side effects like constipation, respiratory depression, itching, tolerance, and withdrawal. But I was essentially taught that if pain wasn’t well controlled with opioids, the solution was to go up higher, or rotate to a different opioid medication. We never covered alternative pain medications, other than anti-inflammatories. We definitely didn’t cover interventional therapies, or even other modalities like knowing when to refer to physical therapy or pain psychology. My education in addiction medicine was equally limited and essentially just covered textbook definitions of addiction, abuse, etc.

When I was an anesthesia resident, I started to learn more about opioid induced hyperalgeisa, which is a state where patients develop increased pain as a result of opioid medications affecting normal pain processing. I also became interested in data/studies suggesting that a multi-modal anesthetic ( the use of a variety of different medications for pain, mainly non-opioids, as well as regional anesthesia techniques like nerve blocks) could improve recovery after surgery and maybe even prevent the transition of acute pain into chronic pain. I also, in the pain clinic, saw the negatives of high dose opioids- severe constipation, terrible tolerance, somnolence (patients falling asleep while talking to me), and still, uncontrolled pain. I became interested enough in pain management that I decided to do a fellowship devoted to extra training.

In my fellowship, I saw such a wide array of patients with various pain conditions. I saw cancer pain patients for whom opioids dramatically improved their quality of life. I saw patients behaving erratically with their medications and calling constantly for early refills, saying things like their wife flushed the pills down the toilet, or they were robbed and the pills were in their purse. I had elderly patients whose family members were stealing and selling their medications- something we only figured out when their drug testing repeatedly came back negative for their medications. It was, quite honestly, exhausting to sort through legitimate pain issues and issues resulting from the incredibly reinforcing effects of these medications.

As a new attending in the community, I then saw the effects of the pendulum swinging in the other direction. Tons of patients flooded my clinic saying that as a result of the new awareness of the risks of opioids, their doctor “could no longer prescribe”. Rather than responsibly taper these patients off, or switch to other medications, many of these patients were left in the incredibly challenging situation of having no one to continue their prescriptions. Abrupt discontinuation of opioids generally isn’t life threatening, but it can make patients feel incredibly sick (like a severe flu), and in patients with other medical issues, can be dangerous. Many of these patients admitted to me that while they were trying to find a new pain doctor, they turned to the street to buy their medications.

In my current practice, I try to be very judicious with the use of opioid prescriptions. Nothing is black and white in pain management- it’s an issue to swing too far in the other direction and say that opioids NEVER have a place in treatment. But I try to be up front with patients about the risks, my concerns, and have a plan to use the lowest necessary dose for the shortest amount of time. I’ve found the vast majority of patients to be well educated about opioids and open to having a discussion. I also take precautions to protect the practice from aberrant behavior, so all new patients get a drug test; I do random screening throughout the year, and everyone signs a prescription contract outlining inappropriate behavior for which treatment may be terminated.

Taking a step back from my own experiences, I think many factors contributed to the current crisis. At the beginning of the high dose opioid era, we genuinely didn’t have many great pain medications as options. Physicians also, as I said above, had very limited training in pain management and addiction, fields which are incredibly complex. Studies were coming out suggesting we were dramatically undertreating pain and that patients were suffering. And drug companies had an amazing product- a very powerful pain medication that causes terrible symptoms if patients stop it abruptly, and inevitably requires higher and higher doses. Who could ask for a better product for a business, honestly?  

Throw in a lack of access to good mental health services, a lack of access to providers trained in addiction medicine/a medication assisted treatment approach (meaning the use of methadone or buprenorphine to treat opioid misuse disorders), and a lack of fellowship trained pain management physicians in the community, and we’ve got a full fledged crisis on our hands. What good is the knowledge that these services save lives when people don’t have access to them?

Furthermore, to be honest, we STILL don’t have perfect pain medication options out there- almost everything I can offer my patients has side effects. I also spend hours a day battling with insurance companies trying to get coverage for these alternative medications/procedures because, quite frankly, it’s cheaper for them to keep paying for opioids. I also struggle with drug shortages, including naloxone (a life saving medication we know should be given with opioid prescriptions), and many medications I use for the opioid sparing injections I perform.

I am optimistic that with the increased awareness of the opioid crisis, there will be progress in policy/legislation to support some badly needed changes.  But I worry, that unless we address most of the factors that got us here, that we may not make the improvements we are hoping for. I’ve heard very little regarding an overhaul of the prior authorization process that insurance companies use to obstruct care. I’ve heard exceedingly little regarding initiatives to train more pain management doctors and get them out in the community. A lot of people who are having issues with opioid misuse started them because of inadequately treated pain! More funding is needed for mental health services and addiction specialists, but what about trying to increase access to pain psychologists? I practice in one of the largest cities in the world and struggle trying to find these services for my patients.

Despite what a tricky time it is to be in this field, I love what I do, and I love helping my patients to improve their quality of life and reduce their pain. Sometimes this requires opioids, and many times not. At this point I am fortunate enough to have had the training and experience to know that every case has nuances that need to be carefully considered.

I hope it was helpful/interesting to hear from the front lines of the opioid crisis! Don’t forget to subscribe to my blog here so you never miss a post!