Walking the Tightrope of Ethical Opioid Prescribing
“I’m not an addict, I am living with chronic pain”
This is the response from millions of chronic pain patients across the nation who are being denied prescription opioids, or who are having their prescriptions reduced. Many of them have successfully used opioid medication to alleviate pain and live productive lives both at work and home. Some of the most commonly prescribed opiates to manage chronic pain include Vicodin, OxyContin, and Fentanyl. These medications have been prescribed for a number of pain conditions, ranging from generalized chronic pain, post-surgical pain management, to end of life care. At the same time, the opioid epidemic has sparked a furious public debate on the ethics and efficacy of opioid treatment for chronic pain.
One of the variables that makes the prescribing of opiates controversial is the fact that everyone has varied perceptions of pain and suffering. A pain level of 7 or 8 for one person could be 4 or 5 for someone else. Physicians are sworn to abide by the Hippocratic Oath which states, “I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.”
Walking the Tightrope
When it comes to the subjective interpretation of pain, a doctor more or less has to take the patient’s word for it. This means that doctors must walk a tightrope between undertreating or overtreating a patient’s condition. They can attempt to validate the report of pain through MRIs and X-Rays to see the physical manifestation of the condition, but the results are not always definitive. Imaging may show no physical evidence as to why someone is in pain – but for the person living with it, it is very real and present.
When this is the case, a doctor may prescribe an alternative pain management solution such as physical therapy; or recommend lifestyle changes such as addressing one’s diet and getting more exercise. If these alternatives fail to help in the treatment process or access to resources are limited, the alternative is a medication (opioids) to manage the pain. While opioid medications are effective at offering quick symptom relief, they have the potential to bring with them a host of additional complications.
Complications with Opioid Prescribing
The most widely known side effect is that these medications are habit forming and may lead to dependence or addiction. This is problematic for a few reasons. First, opioids were originally intended to be used for pain that was unmanageable and impacting one’s ability to function. Patients wanted their quality of life back and the promise of a pill that would eliminate pain was and continues to be very appealing. However, taking opiates to ease the anxiety or other psychological issues associated with a chronic pain condition reinforces a psychological dependency and can set the stage for developing a dependence on opioids.
Physical dependence also becomes an issue with long term use of opioids. According to the American Society of Addiction Medicine, opioid dependence is defined as “a state of adaption that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist”. With prolonged use of opioids, the body’s chemistry begins to change and becomes expectant of the opioid’s presence. At this point if a dose is missed, the body begins to go into withdrawal. Withdrawal symptoms include but are not limited to: cramping, abdominal pain, muscle pain, sweating, nausea, diarrhea, and insomnia.
Once patients develop a psychological and/or physical dependence to their opioid medication, doctors will meet with the patient to discuss the efficacy of the medication. Physicians are often assessing to see if a patient is developing a tolerance to their medication, or if they have developed opioid induced hyperalgesia (OIH).
Making a Transition
Your doctor may suggest transitioning off opioids and switching to a less problematic long-term medication. This is where most patients feel as if they are being treated unfairly, or that they are suffering a consequence on behalf of those caught in the opioid epidemic. Renea Molden shared her personal reaction in a recent NPR interview stating “I was mad, I’ll be honest. I was mad. I was frustrated. It felt like they were taking a part of my life away from me.” Molden says it was hard to leave hydrocodone behind, but she feels good managing her pain without opioids.
Many people share Molden’s sentiment, but the unfortunate truth is that more scientific studies are being published discounting opioids for long term chronic pain management.
Earlier this month, Dr. Erin E. Krebs along with the Minneapolis Veteran’s Affair Center for Chronic Disease Outcomes Research conducted a year long comparative study evaluating opioid’s ability to reduce pain intensity and improve pain related function. The results of the study had the internet buzzing as it found “opioid medication is not more beneficial for long-term treatment of two prominent forms of chronic pain than nonopioid medication” as reported by MDmag.com. For many, this news comes as a hard pill to swallow, but it serves as an opportunity to have an open discussion about non-opioid pain management alternatives.
We know doctors must address and treat chronic pain, but how can it be done in a way that reduces future harm? What is the best path for walking this tightrope of ethical opioid prescribing? Do we eliminate opioids entirely, or reserve them for post-operative and end of life care? Will we embrace studies like those of Dr. Krebs, or reject them because opioids have become a staple in pain management and patients demand relief? Will the Medical and Insurance industries move beyond the bio-medical only approach to pain management and embrace non-pharmacological methodologies? Only time will tell.
Here at A Healing Place – The Estates, we are helping individuals with chronic pain reclaim their lives without reliance on opioid medication. We understand that pain management is much more than addressing the physical elements of the pain, such as the psychological, social and spiritual suffering that often accompanies chronic pain conditions. With over 20 holistic and non-pharmacological modalities, we help our patients transition from passive to active pain management techniques. We understand the importance of creating a relationship with one’s pain, while having the knowledge and tools to prevent and respond to pain flair ups appropriately.
Each patient’s treatment plan is individualized to address their specific conditions and needs in order to achieve a life free from suffering. For more information on our transformative solutions for chronic pain, click here. If you or a loved one is living with chronic pain, call our compassionate staff for a free and confidential assessment at 844-388-4100.