America’s opioid crisis is getting worse. The role of prescription opioids has both the medical establishment and the government justifiably worried.

In response, the National Academies of Science, Engineering and Medicine released an official report on the crisis earlier this year. And, on September 21, the National Academy of Medicine released a special publication calling clinicians to help combat the crisis.

As a bioethicist working on the ethical and policy issues regarding prescription opioids, I am grateful to the National Academy of Medicine for inviting me to serve on this publication’s authorship team, and for taking seriously the ethical component of the prescription opioid crisis. The opioid epidemic is shot through with ethical challenges.

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There are many discussions we could have, but I will here focus on just one of them: the issue of morally responsible prescribing. Should prescription opioids be used at all? And if so, how? The question is obviously important for clinicians, but the rest of us — patients — should understand what our doctors and nurses owe us regarding our care.

Two public health crises

One of the central challenges of the opioid epidemic is figuring out how to respond without harming pain patients.

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If opioids prevent significant suffering from pain, then the solution to the prescription opioid problem cannot simply be to stop using them. To do so would be to trade one crisis (an opioid crisis) for another (a pain crisis).

The data suggest, however, that pain patients’ interests will not always run counter to the goal of curbing the opioid crisis. The evidence favoring opioid therapy for chronic, noncancer pain is very weak, and there’s some evidence that opioid therapy can actually increase one’s sensitivity to pain.

Opioid therapy also comes with significant costs — the risk of addiction and the potential for drowsiness, constipation, nausea and other side effects.

As a result, more of the medical community is realizing that opioids are simply not good medications for chronic, noncancer pain. Getting patients off long-term opioid therapy may well improve their lives.

Should we use opioids at all?

It would be nice if we could simply stop using opioids. But the situation is rather more complicated than that.

Even if opioid therapy shouldn’t be first-line (or even second-line) treatment for chronic pain, that doesn’t mean that it won’t work for anyone. Patients are individuals, not data points, and risks of opioid therapy — as well as the risks of not providing pain relief — are not the same for everyone.

This is important because debilitating chronic pain can lead to a life that seems not worth living, and sometimes even to suicide. In the face of life-destroying pain, if we run out of other options, it’s not clear that we should avoid using a third-line treatment in the hopes of saving a life.

Those who have been on high doses of opioids for years or decades pose another serious challenge. Many of these patients are concerned about the backlash against opioids. Some believe that the opioids are saving their lives. Others may be terrified of going into withdrawal if their medication is taken away.

If we move away from opioid therapy too abruptly, physicians may abandon these patients or force them to taper before they are ready. Tapering, under the best of circumstances, is a long, uncomfortable process. If it’s badly managed, it can be hell. The health care system created these patients, and we don’t get to turn our backs on them now.

 

Finally, opioids are important medications for acute, surgical and post-traumatic pain. Such pain can require long-term treatment when a series of surgeries stretches out for months, or when a traumatic injury requires a long, painful recovery. In these cases, opioids often make life manageable.

Although calls to limit opioid prescriptions generally don’t target these patients, we might reasonably worry about shifting attitudes. If medical culture becomes too opioid-phobic, who will prescribe for these patients?

Responsible prescribing

Fighting the epidemic with nuance will require constant vigilance. In the new National Academy of Medicine publication, we suggest a number of ways that clinicians can work toward responsible prescribing and management of opioids.

In short, clinicians must prescribe opioids only when appropriate, employing nonopioid pain management strategies when indicated. Evidence supports the use of acetaminophen and ibuprofen, as well as physical therapy, exercise, acupuncture, meditation and yoga.

Clinicians must also be willing to manage any prescriptions they do write over the long term. And, at every stage, prescribers should collaborate with others as needed to ensure that patients receive the necessary care.

Although clinicians shouldn’t be “anti-opioid,” they should be justifiably wary of prescribing for chronic, noncancer pain. And when a prescription is appropriate, the clinician should not write for more than is needed.

Patients should go into opioid therapy with a rich understanding of the risks and benefits. They should also have a plan of care, including an “exit strategy” for getting off the medication.

A role for nonclinicians?

The suggestions above may seem straightforward, and perhaps even obvious. So it’s important to point out that this work is time-consuming and sometimes — as in the case of high-risk patients — challenging. Counseling, advising and trying to avoid unnecessary opioid use is much more difficult than writing a quick prescription.

Although this difficult work is still the clinician’s responsibility, the rest of us can make it easier for them to do their job well. After all, no one likes to experience unnecessary pain. Our expectation of powerful pain relief is part of the cultural backdrop of the epidemic.

That expectation is going to have to change. Moderate acute pain from injury, dental procedures or whatever may have yielded a prescription for Percocet or Vicodin in the past. And when we are the ones in pain, we might still prefer that doctors hand out such medication like candy. But the opioid epidemic is teaching us that we don’t, in fact, want that to be clinicians’ standard practice. We shouldn’t demand exceptions for ourselves.

Travis N. Rieder, Ph.D., is a research scholar at the Berman Institute of Bioethics at Johns Hopkins University.

This article was originally published on The Conversation.

The Conversation

  • I want to add to my previous long comment. I know it doesn’t in this article but I don’t think opiate pain patients who get scripts legal jumping through hoops just for some relief should be lumped in with heroin addicts statistically. No disrespect to anyone that’s battled addiction and it start with pain meds. But, I maintain taking medicine so I can get out of bed and live a half way normal life is a super far reach to using heroin.

  • Enough of this nonsense that supposedly opioids are not useful in relieving pain for anything other than merely cancer. That’s total garbage and suggesting that yoga, mediation, and acupuncture should or would be better is dishonest and simply a delusional fiction.

    ‘The evidence favoring opioid therapy for chronic, noncancer pain is very weak, and there’s some evidence that opioid therapy can actually increase one’s sensitivity to pain.’

    The women’s movement said that women should decide their own fate for their bodies, and not the church nor the state. Similarly neither politicIans nor doctors should be making DETERMINANT decisions regarding other people’s bodies either. CERTAINLY not even ‘Travis N. Rieder, Ph.D., .. a research scholar at the Berman Institute of Bioethics at Johns Hopkins University’ should be injecting himself as some sort of genius decider reegarding these issues of controlling other people’s ALLOWED medical care. .

    • I’ve been an opiate patient for 5 years. I take an extended release and immediate release for breakthrough up to 3x’s a day of each. I’ve never once failed a pill count or drug test etc and I’ve never been careless with my medication or addicted. I rarely ever take the immediate release and many times not the extended 3x in a day. Every two months or so I wean myself off my medication and go without even hurting terribly for a few days to make sure just because of my bodies possible physical dependence I can always walk away from them. I also am very honest with my doctor and my psychiatrist about them. For example they gave me dilaudid one time I liked the way that felt it took away the pain but the euphoria effect was much more extensive. I immediately stopped taking them and called my doctor and she changed it to something lower. There are many ways of taking opiates even for long term responsibly. My doctor has told me many times my fear of addiction is the best tool to keep that from happening. I’ve never once done any other med pain, nerve or etc not prescribed. I’ve for sure never went to anything illegal or even thought about it. My point is I’ve tried everything you can think of and more. I was a daily runner, kickboxing teacher etc until 2 years ago when I got sick. I’ve tried any and all things chiropractic, acupuncture, massage, physical therapy aside from traveling to visit a shaman. Opiates are all that makes me able to get up and take care of my family. The only reason I can cook for them, keep the house clean, do homeschool etc.. I am not sure what kind of life I would have without them. As I said I might not take them both 3x a day but I sure take at least extended 2x a day. And there are times I need both or my kids and hubby are eating toast for dinner. I don’t see it as weakness I see it as a tool it’s no different to me than blood pressure meds or antidepressants anything you need daily to be as active as you can be. I get no high from my medicine I also taper off so I don’t need to keep going up to stronger ones. I call it resetting my body lol. The minute you take one because you are sad, mad, having a bad day anything besides pain you are in a slippery slope. But you can use them to better your quality of life.

  • I don’t no how this stopping pain medication got started but it’s stupid totally stupid l had neck surgery and never been in so much pain in my life l also have severe back problems which l will need surgery in the future which ever part of the government got this started l would love to let you have my pain for a day and see just what you would feel like you would change your thinking what is this world coming to it’s ok about people getting drunk buying alcohol and smoking 🚬 and now able to buy cbd stuff l am 62 years old l have never used drugs in my life and because of the people that abuse opioids then people like us having surgeries and chronic back issues and arthritis we have to live every day in chronic pain so how ever this opioid crap got started is so wrong l thought we lived in freedom only when it comes to certain things l was in a car accident in 2005 sitting at a red light and got smashed by 3 vehicles so taking pain medication isn’t something that l wanted to be taking but when you can hardly move you have no choice and then if that’s no bad enough trying to get a prescription with only a ten day supply at one time and Wal-Mart pharmacist asking what do you need it for l am 62 just had surgery l shouldn’t have to explain myself every time I have a prescription filled they are not doctors again l say what is this world coming to before long you will only get an aspirin if your lucky but it’s ok if your speeding and kill someone or you are drunk and someone is killed but if you have chronic pain and have screws and plates in your neck and can’t get a pain medication again l say how stupid is this for who ever got this opioid thing started how stupid can someone be maybe there will come a time when your having chronic pain and you
    will just need to suffer and then you will no what the rest of us are going through and this is for the rest of my life it will never be ok again for me l will be in pain as long as l live.

    • Is there not an exception to the 10 day rule in your state? I’m in Tennessee and I don’t know how it works or what diseases qualify but my script always says “exempt” and it’s for the exception of the 10 day rule. I get 90 of each of my two pain meds a month. They should have a way around it for people like you. I know here you wouldn’t have issue at all. I have severe disk degeneration, Lupus and plates and screws all in my face. I think the cap on any amount of days before 30 is ridiculous.

  • I don’t no how this stopping pain medication got started but it’s stupid totally stupid l had neck surgery and never been in so much pain in my life l also have severe back problems which l will need surgery in the future which ever part of the government got this started l would love to let you have my pain for a day and see just what you would feel like you would change your thinking what is this world coming to it’s ok about people getting drunk buying alcohol and smoking 🚬 and now able to buy cbd stuff l am 62 years old l have never used drugs in my life and because of the people that abuse opioids then people like us having surgeries and chronic back issues and arthritis we have to live every day in chronic pain so how ever this opioid crap got started is so wrong l thought we lived in freedom only when it comes to certain things l was in a car accident in 2005 sitting at a red light and got smashed by 3 vehicles so taking pain medication isn’t something that l wanted to be taking but when you can hardly move you have no choice and then if that’s no bad enough trying to get a prescription with only a ten day supply at one time and Wal-Mart pharmacist asking what do you need it for l am 62 just had surgery l shouldn’t have to explain myself every time I have a prescription filled they are not doctors again l say what is this world coming to before long you will only get an aspirin if your lucky but it’s ok if your speeding and kill someone or you are drunk and someone is killed but if have chronic pain and have screws and plates in your neck and can’t get a pain medication again l say how stupid is this for who ever got this opioid thing started how stupid can someone be maybe there will come a time when your having chronic pain and you
    will just need to suffer and then you will no what the rest of us are going through and this is for the rest of my life it will never be ok again for me.

  • I COULDN’T HELP BUT Take opiods. I have serious Pain. was hit by a car that literally took my leg off. then Put back on, SHORTER enabling extreme pressure on my back. I will be 70, soon, and my quality of life is HORRID. thanks to all the addicts looking for a fix and ADDING fentanyl, cocaine, booze etc…I No longer teach children ages 4-10…what a life.
    NY Nicky

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