By Richard Thorp, MD, FACP
Butte-Glenn Medical Society Past President
California Medical Association Past President
I have been prescribing opioid narcotics for non-cancer pain since I started practice in 1977. Initially, the use of narcotics was extremely frugal and many in the public felt that we as clinicians were not being sensitive to the patient's real pain needs. In fact, it was such a problem that the Joint Commission campaigned successfully to have pain levels recognized as the 5th vital sign. In that culture there was no upper limit to the amount of pain medication given. Over the years, we have seen anecdotal and now more scientific evidence that higher doses of narcotics are not more effective in controlling pain levels. Unfortunately, as in many areas of Medicine, adoption of the science has taken time and now the external culture is demanding a more attentive look at pain control. However, in addition to the good work that has been done and is continuing on improving opioid prescribing safety for patient's and to improve clinician awareness of the challenges involved, there are at least two subgroups of patients on chronic opioid therapy that are inadvertently not being treated well.
First are the chronically stable pain patients with unsolvable pain issues e.g. severe painful debilitating diabetic neuropathy, failed back syndrome after multiple back surgeries and failing multiple other modalities of treatment, and those who have other chronically painful conditions that are not solvable. Many patients continue in severe pain in spite of adjuvant therapy e.g. gabapentin, anti-depressants, anti-seizure medications even after surgical intervention or interventional pain management. There is no current legitimacy given to their condition. In fact, in many cases, this group of patients are demeaned and berated at pharmacies or in urgent care or in ER settings when they try to seek help.
The second group of patients that are having difficulty are those who were treated under the old protocols of "give them whatever it takes to eliminate their pain". There are a significant number of these patients who were given extremely large doses of medications with the idea that "whatever it took to eliminate their pain" was legitimate. As a result many have been titrated up to very high Morphine Milligram Equivalents (MME) many times over the recommended 90 MME/day. Some are still at 3-400 MME/day and have tolerated it without adverse effects. There is no question that they need to decrease their dosing, but the current expectation is that this will happen immediately. There is no tolerance for their need to taper down over a period of time. Pharmacies and Physicians (or Advanced Practice Providers (APPs) are developing a very adversarial relationship. Physicians who are willing to prescribe opiates for these situations mentioned above are being characterized as careless and in "violation" of the recommended guidelines. When in fact, these recommendations by the CDC, for instance, are just that, recommendations. In any other area of medicine, recommendations are taken into account based on the individual and their overall needs. In the case of opioid prescribing, the climate has become so politicized that the pendulum has swung to the other extreme, acting as if, narcotics are evil and anyone prescribing them or using them is careless.
A case can be made that too much narcotics have been prescribed in the past, but I don't believe the answer is to cut people off or down in a draconian fashion without caring for the person and dealing with their individual needs. The art of medicine has always required thoughtful intervention in coordination with the known science at the time. Five years ago, the understanding of chronic pain was very different than it is today. I am in favor of the improved understanding of pain management and the importance of providing patient education and safety in prescribing. However, I do not agree with the current hysteria and politicization that is now associated with opioid prescribing.
I am thankful that Butte-Glenn Medical Society is leading physicians to come together as a community to care for patients who truly have no other option than opioids for pain control while at the same time preventing diversion, leaking of the prescribed medications into the community and minimizing the overall use of opioids as much as possible.
Richard Thorp MD, FACP