A reporter recently asked me about what harm I may have caused as a pain management physician who prescribes opioids. As I reflected on my last 10 years in this field, my response was that the harms I may have caused were because I underprescribed these drugs, not overprescribed them.
I thought of a 25-year-old patient, I’ll call him John, whose sciatic nerve was crushed in a motor vehicle accident, causing excruciating pain in his leg. We knew this would be a life-long injury, and that he would likely have to live with chronic pain. We tried everything I could think of — nerve medications, mindfulness techniques, desensitization, rehabilitation techniques, cognitive therapy, nerve blocks, and spinal cord stimulation — except opioids. John continued to suffer immensely from the debilitating pain, and eventually died by suicide.
Did he die because I undertreated his pain due to my own fear of prescribing chronic, potentially high-dose opioids in a young patient? I cannot know, but I worry and fear that this may be true.
In 2016, the Centers for Disease Control and Prevention published prescribing guidelines for opioids. Though intended to encourage best practices in opioid prescribing, these guidelines fueled providers’ fears of opioids and led to many clinicians abandoning patients who relied on opioids for pain relief. Although even pain specialists like me share fears and doubts about what role these medications play in managing chronic pain, so-called legacy patients are not the same as those who have never taken opioids before, as a colleague and I explained in The New England Journal of Medicine.
Despite a precipitous drop in opioid prescribing since the guidelines were published, drug overdose deaths have surpassed 100,000 in the U.S. in 2020-2021. In response to the unintended consequences of its 2016 guidelines for legacy patients with chronic pain, in February 2022 the CDC proposed revised guidelines that are currently open for public comment.
To be sure, there are many ways to manage pain, and opioids should not be the first approach offered. Pain care can include exercise, physical and occupational therapy, mind-body techniques, coping skills, group support, mental health care, surgical treatment, dietary modifications, and other alternative approaches such as acupuncture and chiropractic care.
Opioids do have a place in pain control and can be safely prescribed, even at high doses, by following best practices while monitoring for risks and side effects. There is no one-size-fits-all approach to opioid therapy or pain management. The revised CDC prescribing guidelines provide a framework for these best practices and alternatives to pain care. It is now up to doctors and other prescribers, along with educators of health care students, to advance the concept of a personalized toolbox to improve the quality of life and function of people living with pain.
People with pain need to know that not treating it — especially chronic pain — is bad for the brain. The brain on pain shrinks in volume over time, but this is reversible when pain is treated.
I sometimes wonder if John would still be alive if I had prescribed opioids earlier for him. I’ll never know. But I do know that although opioids are not my first-line treatment in managing chronic pain, pain care is individualized. There is so much more to managing pain than just the drugs I can prescribe. Understandably, we may fear opioids. But doctors and patients must not be afraid of managing pain.
Antje M. Barreveld is a pain medicine physician, medical director of pain management services at Newton-Wellesley Hospital in Newton, Mass., an assistant professor of anesthesiology at Tufts University School of Medicine, and advisor for Lin Health, an online program for mind-body approaches to managing pain. The opinions expressed here are those of the author and do not necessarily reflect those of her institutions.
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