In Pain: A Bioethicist's Personal Struggle with Opioids

by Travis Rieder

As we think about the dangers of opioids (which we must), we must also think about the dangers of mishandling opioids and withholding opioid prescriptions. The fact that we have prescribed aggressively for decades means that we must deal with opioids in a more nuanced way than if we were simply deciding, for the first time, when to use these powerful medications.

“Prescribe fewer pills” is a terrible goal to give doctors because it makes no reference to the particular patient in front of them at any moment. Some patients will benefit from opioids and some won’t, and so what we really want doctors to do is to prescribe fewer inappropriate pills, while continuing to prescribe when doing so is responsible.

The opioid crisis doesn’t merely raise a problem for opioid prescribing; it raises a problem for opioid management. In fact, we can do better than that: it raises a problem for pain management. What the opioid crisis makes salient for medicine is that we aren’t particularly good at treating pain.

We don’t have a prescription opioid problem; we have a pain problem that opioids happen to play a significant role in.

A strange thing happens when your disability begins to become invisible, though: people stop recognizing your limits (which was exactly what I wanted) and start demanding more of you (a side effect I hadn’t foreseen).

“A physician who prescribes a medication with predictable and harmful side effects is obligated to work to mitigate those side effects, or at least to ensure that the patient has access to someone who will work to mitigate those side effects.”

Pharmaceutical companies and eventually an entire generation of pain advocates moved from the claim that opioids are appropriate in that limited case to the much more contentious (and ultimately problematic) claim that opioids are appropriate in a wide variety of cases.

The benefit of opioids doesn’t mean that we should take them like candy, and the risk of opioids doesn’t mean that we should lock them away and forget about them.

In other words, Tylenol and ibuprofen worked just as well for this sort of pain as did low-dose opioid painkillers. Regardless of whether it might seem like we need something stronger than over-the-counter meds, the data suggests that we don’t really—they can work just as well as the heavy hitters for some acute pain.

The kind of moderate to severe acute pain described above is very different from severe chronic pain that weighs on a patient and disrupts one’s life. Some of the most common forms of chronic pain include lower-back pain and joint pain.

On the one hand, it is completely understandable for a chronic pain patient to ask for something stronger than over-the-counter pain meds. The pain doesn’t let up for these patients, and they can see their lives dwindling to a smaller and smaller level of activity.

On the other hand, though, long-term opioid therapy raises serious challenges.

So just in terms of the basic mechanism of the medication, if a patient is on it for weeks or months, she will develop a tolerance, requiring a higher dose for the same analgesic effect. She will also develop a dependence—as I did—meaning that when she tries to stop, withdrawal symptoms will provide a major obstacle. Since the body’s respiratory and other systems do not become tolerant to the dose increase as fast as they do to the pain-relieving or euphoric effects, increasing the dose increases the risk of overdose. And finally, the euphoric effect on the brain’s reward system makes the drug powerfully addictive.

In fact, for more than two decades of aggressive prescribing of opioids for chronic pain, we had virtually no high-quality evidence of their long-term effectiveness in the chronic pain population.

there is virtually no high-quality evidence that opioids are effective for the management of chronic pain, and there is extensive evidence that they raise patient risk for a multitude of adverse outcomes, including opioid use disorder, overdose, and death.

The group taking opioids did not have increased function or decreased pain over their non-opioid counterparts. Indeed, those on opioids had slightly more pain at the end of the twelve months, as well as significantly more side effects.

Although it doesn’t mean that opioids are never indicated for patients suffering from lower-back or arthritic joint pain, it does cast serious doubt on the practice of using opioids as a standard treatment.

non-opioid therapies work surprisingly well for both acute and chronic pain and have less severe side effects for most people. If opioids are necessary for acute pain, they should be used in very small doses for the least amount of time possible, and for chronic pain, they should be used only after other therapies have been exhausted.

In short, surgery and trauma raise a specific challenge because physicians are likely to see opioid therapy as necessary for this level of pain, but the timeline of recovery can extend to such a degree that it starts to blur the line between acute and chronic pain therapy.

The study found that patients prescribed even just one day of opioids had a 6 percent chance of still being on opioids one year into the future. Much more disturbing, though, was how aggressively that number jumped when the initial prescription was longer. More than 15 percent of patients prescribed opioids for ten days continued use for a year or more, as did a full 30 percent of patients who were given a prescription for more than a month.

In early 2018, another group of researchers looked at opioid prescribing specifically for surgery patients and found that length of initial opioid use also predicted misuse—defined here as opioid dependence, abuse, or overdose. Perhaps

Further, each additional week of opioid use increased the risk of misuse by 34 percent. In short, the evidence on this question is in: longer exposure to opioids, along with increased dose, increases the most serious risks associated with opioid use.

But understanding how quickly dependence can form is crucially important for understanding why larger prescriptions might predict long-term use: stopping the pills can cause withdrawal, and withdrawal causes increased pain and discomfort. It’s not exactly a surprise that more people will continue to take a medication when stopping that medication makes them miserable.

For starters, clinicians need to reduce clearly inappropriate prescriptions: moderate acute pain that can be effectively treated with acetaminophen and ibuprofen simply should not be treated with opioids. That is an exposure point that we can avoid. And, as we’ve already discussed, opioids should not be first-line therapy for chronic pain.

pain is real, and opioids work for some people. In addition, we’ve used this medication for decades, which means we have an entire population of legacy patients, some of whom are stable on very high doses of opioids. Nothing that I’m saying here implies that clinicians should be allowed to be callous regarding patient pain, or regarding the suffering that comes from forced or aggressive tapering.

Sometimes prescription pharmacotherapy is appropriate, even when opioids aren’t.

But some extremity injuries or surgical interventions can also be aided by nerve blocks, which essentially “turn off” the pain-sensing nerves in an area of the body, preventing those pain signals from being sent to the brain.

In fact, an FDA analysis of price trends for opioids reveals that the cost for generic opioids has been less than 2.5 cents per morphine milligram equivalent for more than two decades—a dose literally costs pennies.

From the physician’s perspective, trying to teach patients about different pain therapies and counsel them regarding lifestyle choices can be time-consuming and difficult. In an era of managed healthcare systems, where doctors are allotted mere minutes to spend with patients, these sorts of deep, difficult discussions can seem like a luxury that doctors can’t afford.

Reimbursement can now be tied to these survey results, and so survey scores can affect a hospital’s bottom line. It’s thus not surprising that physicians fear patients giving them negative feedback

So patients at least appear to have significant power over clinicians, in that they can rate them for the public as well as for their bosses.

Compared to the typical doctor, a doctor in the top 5 percent of national prescribers received twice as much money from drug companies; one in the top 1 percent of prescribers received four times as much; and one in the top 0.1 percent—the very highest prescribers of opioids in the country—received an average of nine times the amount of pharma money as the typical doctor.

Understanding the harms and horrors of addiction—even if prompted by the prescription opioid epidemic—needs to change our view of addiction and drug use for everyone. Insofar as we see this crisis as deserving resources, and its victims as deserving sympathy and help, we absolutely must not do so selectively. Treating some people as innocent victims and others as junkies is how we truly fall to the most biting racism charge.

We continue to lack a solid evidence base for much of the prescribing that is done, and the evidence base that we do have is woefully underutilized.

The legacy patients who (justifiably) fear abandonment are some of the most vulnerable in this discussion. They were prescribed opioids aggressively, and in some cases inappropriately, which has resulted in dependence. Now, if they are forcibly tapered or abandoned by physicians, they face truly hellish withdrawal—a form of suffering that could completely understandably drive someone to take their pain management into their own hands by accessing the black market. Physicians must juggle their dual obligations not to prescribe recklessly, while also not allowing their patients to suffer needlessly.