A lot has been written about the potential harms and danger of opioids. These are topics that every patient who elects long term opioid therapy should understand very well. For years, we have all listened to the narrative of opioid overprescribing leading to addiction and overdose deaths. We have also heard a lot about the lack of long-term studies demonstrating the benefit of long-term opioid therapy. The public policy response to the opioid epidemic has been to severely restrict opioid prescribing with the stated goal of reducing opioid addiction and overdose.
While we made strong gains and have successfully reduced opioid prescribing, we continue to watch overdose deaths continue to climb. While the media has recently renamed the opioid epidemic as the fentanyl epidemic, we are having to come to terms with the fact that the simple narrative of overprescribing is an oversimplification and does not tell the entire story. Society’s attempt to reduce opioid prescribing has been very successful. We have increased the burden and the perceived and real risk to prescribers to such a high level that many providers will no longer prescribe opioids.
We have also, through the retail pharmacies and health plans, created formidable challenges for patients to fill prescriptions which is now a relatively new monthly hassle. The unintended consequence, or perhaps the intended consequence that was not well understood has led to real harm, forcing some patients out of the healthcare system to the street corner for pain management. Some patients that were fortunate enough to maintain access to prescribing providers have been subjected to the harms of rapid tapers based on poor understanding and misinterpretation of medical board and CDC opioid prescribing guidelines. If that is not enough, many patients describe horror stories dealing with overzealous pharmacists and chain pharmacy “policies” that create patient stigma and ostracization like clockwork every month.
Society’s focus on addiction and opioid use disorder (about two million patients) is important, but not at the expense of roughly twenty million patients that utilize opioids effectively for independence and quality of life. For these patients, there is an ever present uncertainty about their ability to maintain access to a treatment plan that has been effective and improves the quality of their lives. This is undeniable. As prescribers experience increasing regulatory requirements, diminishing reimbursement and increased practice costs, it is easy to understand that the needs of the complex chronic pain patient are at risk.
The greatest area of impact is to patients and providers in primary care. Roughly half of prescribed opioids come from primary care. Patients that suffer from chronic pain typically have several chronic conditions whose management must be carefully orchestrated and coordinated. Primary care is currently facing care provider shortages and high rates of burnout.
What does all of this have to do with the benefits of long-term opioid therapy? We must shift our perspective from the statistics, trends, stereotypes and generalized studies and turn our attention to the individual, specific patient. This is an important perspective because we are not arguing against the rear-view mirror, but rather, we are looking to the future and the function of a patient, one patient at a time. How do we know a patient benefits from long term opioid therapy? In most cases because their pain management is stable, they are productive and they can articulate how the opioid helps them to live a more normal life, in spite of their pain condition. They can describe the functional improvements in a measurable way. The benefit comes from the ability to live independently and pursue vocational, social, community and family activities – to meet their responsibilities to care for themselves and others. Their ability to maintain quality of life and pursue personal goals that enrich their lives and the lives of others is proof of the benefit. This is often the narrative that is missing from the clinical note. The justification and demonstration to continue the treatment, based on real benefit.
For patients, this is a very important point to understand. While access to adequate pain management is very difficult, patients have a responsibility to assist their prescriber in making sure the benefits are clearly articulated so they can be well documented. This is accomplished in many ways and unfortunately creates yet another burden for the patient. It usually comes in the form of questionnaires, monitoring, additional specialist appointments, insurance forms, and additional assessments. All of these are expensive and time consuming. It is understandable that the immediate reaction from patients when confronting this new burden can be frustration. It is important to keep in mind that on the other side of this coin is the prescriber who can feel equally frustrated by the hoops they have to jump through in writing the prescription and ensuring that they have dotted all of the I’s and crossed all of the T’s so they may manage the threat to their medical license that is real. They are not doubting the benefit of long term opioid therapy.
Prescribers continue to manage patients on long term opioid therapy and witness the benefit for each patient, otherwise they would not write the prescription. They certainly don’t enjoy the hassle factor. It is critical that patients work with their prescribers to help articulate and demonstrate the benefit so it can be appropriately documented. It is the evidence to confront and manage the generalizations. If you are a patient, remember this next time your prescriber is asking you to do one more thing – they are asking because they want to keep supporting your treatment choice for long term opioid therapy and they are agreeing with you that the benefit is real.