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.
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:
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.
Peter 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.
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