The Orphaned Patient: Treating Chronic Pain with Opioids

Sad Young Woman in Doctors Office

By Peter Grinspoon, M.D.
February 1, 2018

[Part 1 of a 3-part series.]

The commonly cited proverb, “The road to hell is paved with good intentions,” was coined in the twelfth century by a French abbot named Bernard of Clairvaux. In no case is this adage more apt than as applies to chronic pain patients, who have been cut off from their longstanding and stable supplies of opiates by physicians who have been convinced, cajoled, intimidated, mandated, and cowed into no longer prescribing high-dose opiates for chronic pain patients in response to the current opiate epidemic.

Many of these patients are finding themselves “orphaned” and cannot find prescribers to resume these prescriptions once their doctors have either decided to stop prescribing opiates altogether, or have retired or left their practice for any other reason. Many doctors decline to accept new patients on high doses of opiates because of the liability, the time-commitment, and the hassle.

In response to our current opioid epidemic, which is costing so many families their loved ones, the Center for Disease Control came out with guidelines in 2016 for primary care doctors that recommended specific upper limits for how high a dosage most chronic pain patients should be on. These recommendations, which were intended to be voluntary, suggest that clinicians, “avoid increasing dosage to ≥90 MME/day [morphine milligram equivalent] or carefully justify a decision to titrate dosage to ≥90 MME/day,” and go on to state that:

“benefits of high-dose opioids for chronic pain are not established…the clinical evidence review found that higher opioid dosages are associated with increased risks for…opioid use disorder, and overdose.”

The CDC recommendations have been interpreted by many physicians as a mandate, and this perception has been reinforced by state lawmakers, medical boards, insurance companies and hospital executives, all of whom are creating overt and subtle pressures on physicians to prescribe fewer, if any, opiates in response to either acute or chronic pain. This new “anti-opiate” climate has been widely interpreted to mean that patients should be forced to taper down their doses of opiates to levels at or below the recommended levels, if not taper off of opiates altogether. There are laws in several states that actually restrict how high a dosage of opiates a doctor can prescribe for a chronic pain patient (usually excluding cancer, hospice, or palliative care).

One can argue whether many of these chronic pain patients should have been started on such high doses of opiates in the first place, but unfortunately, millions of chronic pain patients are already on doses of opiates that are significantly higher than the recommended 90 MME/day, and have been for quite a while, without problems. As a result, this new climate of forced tapers and physician abandonment, as well as of drug screens, opiate contracts, and pill counts, has been absolutely traumatic for chronic pain patients. They feel as if they have done nothing wrong and are now being treated as “addicts” and criminals. A prominent anti-opiate activist refers to opiates as “heroin pills” which increases the stigma associated with these medications. Increasingly, stories are being circulated on social media and in the press of these “orphaned” chronic pain patients resorting to much more dangerous street drugs, or even committing suicide, in response to the utter agony and despair of their untreated pain.

While most would agree that attempts to lower the overprescribing of opiates are well intentioned in the face of an opiate epidemic that is killing more than one hundred people a day, fewer would vouch for the effectiveness of these efforts in the face of such a complicated and multifaceted crisis. In fact, overdoses from opiates have actually gone up in the last few years despite the fact that prescriptions for opiate painkillers have gone down, showing that many factors are at play beyond the mere overprescribing of opiates. In any case, as doctors, we as a profession must listen to the cries for help from our chronic pain patients, and we must decide, free of external influences and pressures, what truly is best for our patients.

Through the lens of compassion, we must consider whether the pendulum is perhaps careening too rapidly and aggressively away from the treatment of chronic pain patients with opiates, and whether there isn’t a middle path that can more judiciously balance the need to treat pain with the need to prevent addiction.

Reference

1. Dowell, D,  Haegerich, T,  Chou, R., CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.  Morbidity and Mortality Weekly Report. (MMWR), Mar 2016


To disseminate the latest evidence-based research and recommendations in identifying and treating patients with opioid use disorder, Harvard Medical School is offering free online education:

The Opioid Use Disorder Education Program

This program is designed for nurses, nurse practitioners, physician assistants, physicians and other health care professionals collaborating to treat patients with substance use disorder and offers up to 24 CE/CME credits.


 

Dr. Peter Grinspoon profile photoPeter Grinspoon is the author of the memoir Free Refills: A Doctor Confronts His Addiction. He currently practices as a primary care physician at an inner-city clinic in Boston, is on staff at Massachusetts General Hospital, and teaches medicine at Harvard Medical School. He spent two years as an Associate Director for the Physician Health Service, part of the Massachusetts Medical Society, working with physicians who suffer from substance use disorders.

Follow on Twitter: @Peter_Grinspoon

Subscribe to the Harvard Health Publishing newsletter for addiction and recovery information: Breaking the Cycle

*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

24 thoughts on “The Orphaned Patient: Treating Chronic Pain with Opioids

  1. Thank you Dr. Grinspoon :’) … Your astute article laced with so much compassion and zeal for both patients and your professional Oath means so much to me right now as an ‘orphaned patient’ myself, as someone with EDS type 3 and so many complications from its degeneration I have been utterly ‘dumb stuck’ by all that’s happened/ still happening to my fellow disabled/chronically ill and in pain community…. The trust, esteem and respect you have for your doctors is almost a measurable when your life and lively hood is being truely saved by them everyday with their expertise and in the effective individualized care they give, and Nothing is as heartbreaking for us than to lose that person and trust, when many times it was possibly only our Dr. that once understood through medicine and science how real our pain really was and is…. God Bless you:) Thank you for refuseing to abandon your Oath!

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  2. There are pros and cons of opioids. My husband would have committed suicide along time ago without them or be a raging alcoholic. Our journey has ben long with many therapies and many different drugs. We know the risks to the liver, kidneys, stomach and heart. He gets regular blood and urine tests. To just cut these patients off or even reducing their doses is going to cause a whole new set of problems. There will be a definite rise in illegal drug use, alcoholism and all the crisis that goes along with that, and a rise in suicide rates. No one wants pain. No one asks for it. No one wants to take the meds. This is the life we have, and for opioids to be taken away entirely, will be the end of it. But since we’re being seen as such a burden, maybe that’s what they want. Then we all wouldn’t pop that perfect bubble they surround themselves with.

    Liked by 1 person

  3. My understanding opiates work for pain with out causing the horriable side effects like holes in your stomach killing your liver shots in your joints that disintegrate your bones kills your kidneys – if they are the best option to treat pain there is no reason to stop using them none of this opiate take over over by gov regulation makes any sence at all its definitely not in the best interest of the public/patient

    Liked by 1 person

  4. The problem is not just limiting or cutting the patient’s opiates down…it’s leading them to a better choice with medication assisted treatment…Suboxone, Vivitrol, or Methadone. Most PCP’s have no idea where to send their patients. I am a Suboxone provider with 110 openings right now but no one knows who to call!!

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    1. You’ve written a very bizarre response to the issues raised in the article. Trolling for clients? Cash only clinic?

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    2. I would like your professional opinion doctor. Why is suboxone with a 30x stronger than morphine or methadone 12x stronger than morphine ok to use yet hydrocodone with a 1/1 or oxymorphone 3/1 to morphine not okay. Why the rapid progression to the strongest non fentanyl opioid as a path to treatment for intractable pain?

      Liked by 1 person

    3. Lisa, I live in WA. state. Where are you located? Would you be able to help my situation? Do you accept medicare? I never thought growing old with advanced debilitating arthritis, would give me so little voice or energy to voice my opinion. Wish all that are suffering could show up at the capital. But who has the energy and money to do that? Is this the new way for the Gov. to knock off the sick and elderly?Sure makes me wonder.

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    1. I think that unfortunately methadone is somewhat stigmatized as a medication because it has been used to treat addiction and that a lot of doctors aren’t comfortable using it. Also – not that doctors are feeling pressure not to prescribe opiates, methadone falls into that category…

      Liked by 1 person

        1. The drugs that are comparable to methadone (assuming we are talking about using it to treat chronic pain and not addiction which is another situation) are basically all of the other opiate painkillers such as (as you mentioned) Tylenol #4, tramadol (though this is part opiate and part another type of medicine so it is partially in a different category), hydrocodone, morphine, oxycodone, etc. They act on the same receptors in the brain and offer pain control via the same mechanisms, but differ in their side effects, how long they last and their cost. Methadone is inexpensive, has been around for a long time, and has a long half-live, meaning it gives long-lasting pain relief, but it can be unpredictable in how it effects different people and can have some serious side effects including heart arrhythmias, which can lead to death. Often, people opt to use different long-acting opiates for pain control for these reasons, though I know many patients that have done well on methadone.

          Liked by 1 person

          1. The heart arrythmia side effect is quite rare. Anyway, methadone is the only opioid that doesn’t build resistance. I have been prescribed 60mg a day for 10 years, and it has provided good pain relief. 2 days ago, I go to my board certified pain MD, and am told he will “have” to drop me down to 20mg a day, over the next 3 months. The new “rules” from the CDC, he said.
            Thanks CDC, and Sessions, and Trump!
            I am mad as hell.

            Liked by 1 person

            1. The CD C doesn’t require your doctor to drop your amount. The CS Chad only published recommendations. It’s doctors, insurance companies, legislatures, etc that are treating them as requirements.

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              1. It is true that what the CDC published were guidelines and that these have been misinterpreted as mandates/requirements or have been deliberately misrepresented as such to limit physician prescribing of opiates.

                Liked by 1 person

            2. I’m just seeing this, I am so sorry. My husband is in the exact same position. Using Methadone for pain for 15 years. Same dose, same doctor for 10 of those years. Now he is being reduced and doctor says soon no one will receive over 20mg. It is inhumane!

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  5. I just wish i could get on opioids. I went to a pain management clinic. I didn’t even SEE a doctor and every single one of the nurse clinician’s recommendations were either things that had already been attempted by other doctors or were impossible because my insurance wouldn’t pay for it. I still have the recommendation sheet in my purse and I intend to tell my own doctor this was a useless appointment and like taking a squirt gun to a house fire and expecting to put it out.
    There is a rising incidence of people with chronic pain committing suicide just because they can’t get treatment. This is a blot on the entire medical profession.

    Liked by 1 person

    1. I agree that the medical profession has to do better. So does the insurance industry; they have to pay for the alternatives to opiates for pain management such as physical therapy; its awful that/when they don’t!

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          1. Exactly. The CDC claims innocence re guidelines as DEA has weaponized. I find it funny that they have changed the MME for methadone. It was 3 times the dose in 2014, now 10 times. There is an agenda. So much money is being spent on this false narrative people in pain are being treated like criminals and forced on to suboxone which is not for pain

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