The Pendulum Has Swung Too Far

Treating Pain in Primary Care

Linda Brookes, MSc


February 22, 2019

In This Article

In the war on opioids, the main casualties are usually identified as the people who misuse or abuse the drugs and are at increased risk of dying from an overdose.[1] However, since regulators tightened opioid prescribing rules in the United States, another group of victims has emerged: the so-called "legacy patients," often elderly, with non–cancer-related chronic pain that was successfully managed with a regular dose of a prescribed opioid analgesic. Many of these patients have had their medication reduced or even withdrawn, often with distressing and sometimes tragic consequences.[2,3]

I am really worried about the path toward addiction; but not for whom we've tried everything else.

Stories abound of patients unable to tolerate a forced tapering of their dose. Other are cut off from their medication completely by physicians or pharmacies who face pressures to change opioid prescriptions.

"These patients are undoubtedly discriminated against," says Charles Vega, MD, clinical professor of family medicine at the University of California, Irvine. "They are viewed as drug-seekers, whether they have drug-seeking behavior or not, and it makes them ashamed. There is a psychological toll."

The plight of these patients has provoked reactions from organizations as disparate as Human Rights Watch, which issued a report about patients feeling "abandoned and stigmatized by the healthcare system,"[4] to the TV channel Fox News, which screened a series of programs highlighting the "overlooked victims of America's opioid epidemic."[5,6,7] Patient groups, such as Don't Punish Pain, have been formed to protest the "arbitrary restrictions" on opioid medications introduced by the US government.

Chronic Pain Patients Are Not All Created Equal 

"We have a crisis that has precipitated a set of policy responses that many clinicians adhere to in almost a religious kind of way without acknowledging variation at the patient level," says Cary Reid, MD, PhD, associate professor of geriatrics at Weill Cornell Medical College, New York, New York.

Vega agrees, noting that although only a minority of patients really need opioid therapy, "we are painting with such broad strokes now in this crisis mode that they are negatively affected by it."

He recalled the case of a 72-year-old retiree with chronic degenerative disease of the spine. "She also had stage IV chronic kidney disease, hypertension, and diabetes, all fairly stable and well-controlled. It would be a huge mistake to put her on chronic anti-inflammatory drugs; acetaminophen doesn't do enough, and she has trouble accessing physical therapy," he explained. "What really sets her free is tramadol once a day, which she takes in the morning. And then she uses acetaminophen the rest of the day. When I last wrote her the usual prescription, the pharmacy denied it, saying she didn't have a chronic condition and was at risk for overdose. They didn't notify me and she went 10 days without therapy. She finally called me, asking why I had withheld her medicine, and I didn't know what she was talking about."

"That is the environment we are living in, and it is a real shame. I understand the value of safety regulations," he stresses. "I stay away from opioids in most patients, even for acute treatment, because I am really worried about the path toward addiction—but not for 72-year-olds who have become accustomed to them and have used them for a long time, and in whom we've tried everything else and nothing else works."

Brad Fox, MD, chairman of the Department of Medicine at Saint Vincent Hospital, Erie, Pennsylvania, is also concerned that the regulations treat every patient as equivalent. He cited the case of an 80-year-old patient who had been taking hydrocodone 2.5 mg every 6 hours for 12 years. "He hasn't asked for more; he doesn't take them more frequently; and he calls me every 30 days and gets 120 tablets, which the guidelines see as a bad addiction. I really don't care if he may be addicted to it; he functions very well on his current medications," Fox declared.

"If there is ever a case for patient-centered care, it is probably the chronic pain patient, especially the older chronic pain patient," Vega suggests.


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