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The Consequences of Our War On Opioids

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As a board-certified specialist in both pain medicine and addiction medicine, I am deeply disturbed by the promulgation of misleading statistics by self-proclaimed experts and agencies such as the CDC and VA, and I am concerned about the effects that their actions are having on many of my patients struggling with chronic pain. Using flawed logic, they contend that there is insufficient evidence proving opioids are effective for long-term use in chronic pain and that consequently the risks of such use outweigh the benefits (1, 2). This assertion is predicated on the fallacious assumption that limited evidence of long-term effectiveness of opioids in clinical trials 

is equivalent to absence of such effectiveness. By no means have opioids been proven ineffective for chronic pain. On the contrary, any experienced pain medicine practitioner recognizes that opioids are essential for many of our chronic pain patients. 

Pain is inherently subjective. It cannot be measured with a blood test or visualized on an MRI. Sadly, this subjectivity not only methodologically confounds the design of high-quality clinical trials but also allows for the callous and offhand disregard of chronic pain patients' self-reported relief from opioid therapy and the portrayal of them as being weak, addicted, or simply in need of finding other means to manage their pain. Most of my patients on chronic opioids have exhausted every other available treatment option. 

Pain specialists utilize tools for stratifying an individual's risk of opioid addiction and closely monitor patients for signs of addictive behavior, thereby further mitigating that risk. It is important to recognize the fact that there is no class of drug that is devoid of risk. As an example, the risks associated with NSAIDs like ibuprofen and naproxen include morbidity and mortality due to bleeding, kidney and liver damage, and/or thromboembolic events such as heart attack and stroke. Acetaminophen is available over-the-counter and is widely assumed to be safe, yet all of us recognize its potential to cause liver damage at doses as low as four grams per day. Are we calling for a ban on NSAIDs or acetaminophen? In the zeal to curb opioid related deaths, legitimate pain patients who are benefiting from opioids and are using them appropriately and responsibly with positive results, along with the doctors treating them, are being directly targeted. Forcing such individuals to taper below an arbitrary dosage or off opioids entirely and discouraging physicians from prescribing them for legitimate chronic pain patients is nothing short of barbaric. The term "risk-free suffering" has been used elsewhere to highlight the increasing tendency of physicians to focus only on opioid risk and ignore benefit. While there are undoubtedly risks associated with the use of opioids, I wholeheartedly believe that prescription opioids continue to have a major role to play in the management of chronic pain. For many, they are truly a quality-of-life saver. I have patients under my care who live productive and rewarding lives because their opioid regimens enable them to function at work, care for themselves and their families, and experience enhanced quality-of-life that would be otherwise impossible for them. 

Equally alarming is the harm that is being inflicted upon chronic pain patients under the pretext of protecting them from opioids, despite mounting evidence that it is not prescribed pharmaceutical opioids but illicitly manufactured fentanyl and heroin that is responsible for the large majority of opioid related overdoses and deaths (3, 4). I propose refocusing efforts to fight the scourge of illicit street drugs flooding into the country, not endeavoring to limit access to opioids for chronic pain patients. We are dealing with an illicit heroin/fentanyl crisis, NOT a prescription drug crisis. I firmly believe and my experience dictates that appropriately selected individuals using prescription opioids for legitimate pain management purposes are unlikely to become addicted. Numerous studies bear this out (5, 6, 7). Because some individuals with chronic pain can manage without opioids does not mean all can. Because some may misuse opioids does not mean all do. A "one size fits all" mentality under the guise of "evidence-based medicine" is increasingly harming patients and the entire medical profession. 

Another point. Death certificates do not differentiate suicides precipitated by intractable, untreated, or inadequately treated chronic pain from suicides in general. This hidden statistic enables anti-opioid zealots to argue that such suicides are not occurring. An increasingly compelling body of anecdotal evidence suggests otherwise.

Finally, the CDC's Guideline for Prescribing Opioids for Chronic Pain is being widely misapplied to the extent that the CDC has posted what amounts to a mea culpa on their website advising, "The recommendation statement does not suggest discontinuation of opioids already prescribed at higher dosages," and, "Policies that mandate hard limits conflict with the Guideline’s emphasis on individualized assessment of the benefits and risks of opioids given the specific circumstances and unique needs of each patient." These statements acknowledge the fact that there are individual differences in rates of opioid metabolism and that patient harm is occurring as a result of forced tapering and/or discontinuation of opioid medications by misinformed and overzealous practitioners. This is a consequence that many of us predicted and warned about, to no avail. The problem for pain medicine practitioners is that it has been exceedingly difficult to reverse the harm that has been done as a direct result of these guidelines. 

Consider the following examples: 

• In 2017, the DEA reduced the amount of almost every Schedule II opiate and opioid medication that may be manufactured in the U.S. by 25% or more. This has hampered opioid supply leading to hospital shortages and cancelled surgeries.

• Now, for the eighth year in a row, the DEA is recklessly planning to cut production of opioids yet again.

• Many insurance companies and pharmacy benefit managers have imposed strict limits on opioid dosage.

• Medical boards and law enforcement agencies have been strictly interpreting CDC Guidelines and targeting physicians who treat chronic pain. This has had a chilling effect on many pain specialists and has caused many to abandon patients and/or refuse to accept new ones.

I am concerned we are training a generation of opioid-averse "pain minimizers" — physicians unwilling to consider prescribing opioids for intractable chronic pain, even when everything else has failed and no other effective treatment options exist. Since chronic pain can afflict anyone, we should all be afraid. 

As both an addiction medicine and pain medicine specialist, I am fully aware of the magnitude of the opioid crisis. Our mission should be to expand access to treatment for those with opioid use disorders while aggressively working to curb the flow of illicit heroin and fentanyl into our country. I am most certainly in favor of expending greater resources in these efforts. However, we must not lose sight of the fact that chronic pain and the suffering it causes is a reality of life for many. It does not attract a great deal of attention in the media and people suffering with chronic pain tend not to draw headlines. But as physicians, we have a profound duty to relieve pain and suffering. A balance between effective pain management and mitigating opioid risk must be our stated goal. Chronic pain patients must not end up as collateral damage in the "war" on opioids. 

Dr. Ladin is a clinical assistant professor of neurology at University of Arizona, College of Medicine and a clinical assistant professor in the Department of Clinical Education at Midwestern University AZ College of Osteopathic Medicine.

Illustration by April Brust

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