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.


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.

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.


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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

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  • I have spinal stenosis 7 disc in back of neck removed spacers implants and fusion 3 disc in front of neck implants and fusion with rods and plates holding me together I’m in pain constantly. Had open heart and this ignorant government want to take the meads away that work best go after the abusers and bad Doctors oh I’m sorry the government would have to get up off their buts and work for their over paid salaries!!!!

    • Dear, Mr. Packer sorry you’re not very great at handling pain, there is however a life away from being addicted to opioids/heroin based drugs. Spend less time complaining and more time with your physical therapy. The government enforces the law of the land, if you dislike maybe you should move to a different country. When speaking of the ignorant government you made some ignorant grammatical errors “want” to take your ”meads” away, I assume you mean wants to take your meds away, also “buts” would be spelled butts if referring to the buttocks. Lay off the pills… – God Bless

  • I’m a chiropractor helping patients who were prescribed opioids in the past. I use conservative drug free methods that address a significant cause of chronic pain. Imbalance in the spine and the musculoskeletal system impacts the nervous system and how the body functions. When they get chiropractic, they notice significant relief and wonder why no one told them about this healing art in the first place. I wonder the same thing.

  • Who wrote this fictional story? What planet are they referring to? Planet Perfectoid? Do you expect anyone with a positive I.Q. to believe any of this crap? Smells like bull faecal matter to me.

  • The Greatest Obstacle we face is not the practice of labeling an event in time as a particular indicator of a future event but in the notion that we are not currently applying the facts to the issue at hand.

    Political Insanity is what we are looking at here.

    We have the CDC in a role of modifying statistics in such a way that we have serious minds applying great effort to fix a problem that only exists on paper.

    Overdose related data correlated by the CDC has not been accurately compiled.

    In such a situation we face defeat.

    Overdose where the patient ingested multiple illegally obtained substances otherwise known as street drugs and then combined with alcohol is the single greatest cause of overdose deaths.

    Overdose deaths where prescribed pain medications were the sole cause of death are statistically so low that numerically it would appear less than one percent and in fact likely represented as 0.003

    The CDC admits that they do not separate deaths from prescription pain medication from those that also include heroin, alcohol, illegal pain medication, street drugs, bath salts and any other modality.

    They compile all deaths together.

    In a world where we claim that we believe that we have progressed in scientific knowledge how do we arrive at a situation where we fail to address the reality of statistic’s in favor of political analysis.

    Consider further the side effects of alternate pain treatments with synthetic and or injections of steroids as an alternative to a medication that is cheap and has few side effects when properly managed by doctor and patient.

    Simply put if you believe that prescription pain medication is creating a crisis of overdose deaths then you are frankly just uninformed.

    • Attributing the cause of death to prescribed opioids when other substances or illegally acquired opioids are involved is clearly going to cause serious mistakes in any cause-effect analysis.

  • Opioids should be available to anyone with pain that wants them. I have chronic pain and I am somewhat young and I am lucky that I found a doctor who will prescribe opioids for my pain. I am going to start physical therapy soon and I have been with a previous doctor who insisted that I get tons of injections or he would t prescribe opioids. The injections hurt and didn’t work. And he didn’t prescribe enough opioids. My new doctor prescribes good amounts of opioids and doesn’t mandate stupid injections. I don’t sell my pills so i am not in any way contributing to the problem. People just need to chill. God I had to jump through so many hoops with my primary care physician to just get tramadol and then my last pain doctor would prescribe morphine but barely any. He was obsessed with trying to get me off opioids too. I never understood it why would I want to stop something that is helping me. My new doctor is great though. I get dilaudid now and that is the best drug I’ve ever taken for pain. And it makes me feel good too which is ok with me.

  • Prescribed beyond a few weeks is what’s causing addiction. It’s science. All those medically addicted must seek alternatives or they risk adverse reactions.

    • I would have to disagree with the statement that addiction is caused by prescribing beyond a few weeks. There are plenty of cases where the person becomes addicted after a short course of opioids, or taking some pills recreationally. There are also plenty of cases of patients, the ones I have on opioid medication who have been taking a low dose ~20 mg MME per day for years with no increase and no other drugs. With this many counterexamples the statement that prescribing beyond a few weeks causes addiction is disproved. The reason I am taking the time to point this out is that simple statements like that make it difficult to sort through the many factors that cause addiction in one person and not in another.

  • Opioids should be prescribed only to a “controlled” environment. We have lost “controll” of controlled substances in this country due to the pop a pill conditioning and reinforcement by the pharmaceutical companies.

    • I don’t think you would say that if had chronic pain that had taken over your life and opioids had given you back your life. I’ve been on a stable, but high dose for may days with no problem whatsoever. Only benefits.

  • Having read this article and the referenced publication from the National Academy of Medicine it seems clear that the authors are seriously out of touch with the realities faced by treatment providers and the realities faced by patients with pain. I am quite sure that few, if any, of the authors has had to work 40+ hours per week actually treating patients with pain under the constraints imposed by insurance companies and Medicare/Medicaid for non-opioid treatment for pain. I am also quite sure that few, if any, of the authors has suffered with severe chronic pain with as little social support and as many financial pressures as most patients with chronic pain. From my perspective in the trenches the authors come across as a bunch of Marie Antionettes saying “Let them eat cake.”

    Prescribers are already changing their practices and prescribing fewer opioids. However, non-pharmacologic techniques are often not covered by insurance. I have a patient who needs PT but her insurance will not cover it and she is out of work and so can’t afford it. Her insurance will cover oxycodone though.

    Buprenorphine can be effective at reducing pain and used in place of a full opioid agonist. No special DEA waiver is needed to prescribe buprenorphine for pain. I checked on this with the DEA to be sure. BUT Medicare and many insurance companies will not cover buprenorphine for pain. They only cover buprenorphine/naloxone for opioid use disorder. That requires a special waiver from the DEA which few physicians have. It also means that if the patient does not have opioid use disorder, but simply has chronic pain then their insurance will not cover the buprenorphine, even though it is safer and has less abuse potential.

    Another issue is that I continue to see “abuse deterrent” formulations of opioids being marketed. This is utter nonsense from the drug companies and the physicians who speak for them. Sure the formulation makes it so the drug can’t be injected or inhaled. But most abuse is associated with oral use and these formulations do nothing to prevent that. The level of deceit in the name “abuse-deterrent” is obscene, especially when the companies lobby for laws that force insurance companies to pay exorbitant prices for these formulations, but there is no such lobbying to force insurance companies to pay for non-pharmacologic treatments.

    The authors seem clueless about how few treatment providers exist to provided such non-pharmacologic treatments outside of major metropolitan areas served by one or more large academic institutions. So even if a physician wants to refer a patient for CBT to help with their chronic pain, there is often no therapist available who truly has expertise with that population. Even if such therapy is covered by insurance, the insurance company rarely “authorizes” enough visits and the co-pays for the therapy are usually beyond the ability of the patient to pay.

    I would like to see a set of guidelines written by physicians who are working full-time treating chronic pain in the real world, not in an academic institution, and by patients who are actually suffering from chronic pain.

    • As a chronic pain patient that has been in the trenches for a decade, thank you so much for accurately describing reality.

    • OK Doctor Joe…I was prescribed oxycodone (Percodan) first in 1985. Due to countless leg & knee surgeries as a result of a distant MVA, I’ve been prescribed oxycodone in some form ever since. I was put on Fentanyl patches in lieu of OxyNeo back in 2008. Well, in the summer of 2016, my doctor cut me off Fentanyl COLD TURKEY, and gave me a medical marijuana prescription. WOW!!! Five years before that, she (the “doctor”) she’d say something similar to, “How are the OxyNeo’s working Gerry? Should we raise it…I think so eh? Oh, I see you smoke marijuana, you should cut down on that stuff…bla-bla-bla…” I was suffering withdrawal for weeks, and went to the methadone clinics. The methadone clinics in town said they could not help me, because I had more of a pain issue than an addiction issue…WHAT? That’s not what they’ve been saying to me for 40 years…quite the oppisite to be honest. I was at my rope’s end when I went to her office and almost cried in frustration…told her this was ruining my life. She then asked me what would make me feel better…WITH A 25 micrgram Fentanyl patch in her hand!!! Like she was teasing the drug addict. I replied “That thing in your hand would be a start.” I said. So she made me return into her office and started me back on the patches, but at half the doseage…from 50 micograms to 25. Just last summer, she decided to cut me off completely, saying in front of over a dozen strangers in the waiting room, “We’ll stop you from being a druggie, and give you back your life.” Now, I go to the OATC every day, and take methadone, which I suffer from all or most of the side-effects. I cannot function on methadone, at least not when I take the amount that eases my chrnic pain in any fashion. The College of Ohysicians & Surgeons of Ontario are a sham, they do nothing to help you as a patient. They protect the doctors in every aspect…I tell the truth, the doctor replies it didn’t happen that way…CASE CLOSED. Where are we, 1940’s Germany? This will likely be the end of my life. Good work to the medical community.

  • With crazy ideas like this, it is relieving the author is not an MD! I don’t think anyone rational would suggest increased suffering for the greater good, no matter how many addicts it “saves”

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