February 3, 2015

Changes in opioid prescribing

Since late 2012, there has been an enormous sea change in how opioids are used.  From about 1986 to 2012, the prevailing thought was that pain was undertreated and that patients should be provided whatever opioids they needed.  This was for any type of pain, whether cancer pain, low back pain, pain from disc herniations, facet disease, spondylosis, spondylolisthesis, arthritis of the spine, sacroiliac disease, complex regional pain syndrome or reflex sympathetic dystrophy, fibromyalgia, irritable bowel syndrome or chronic fatigue.

This belief was widespread and was incorporated into Medical Board treatment guidelines.  In California, the Medical Board mandated, and still mandates, that all physicians must take training in chronic pain.  Despite this effort, there was not much change in the amount of pain.  We were not seeing, or even looking for, much change in the amount of function chronic pain patients had.

In 2012, the Centers for Disease Control issued a report that instead of helping people, opioids had become a major public health problem.  As many people were dying from opioid use as were dying from car crashes.  From my personal perspective, all of these deaths were preventable.  From the charts I have reviewed, these deaths are occurring in patients who have a medical reason to be prescribed opioids.  While there are some doctors who are just prescribing to addicts who then overdose and die, that is the exception.  My impression is that in patients who dye, there is a balance between their general medical condition and their opioid use.  When they die, something happens. We usually cannot be sure what happens.  They may overconsume, or they may not.  They become more physically active, as in moving from one apartment to another, in the face of being decondition, or they may have a decline in their medical condition, as in getting the flu.  Other times, they are taking opioids in conjunction with other sedatives, such as benzodiazepines, like Xanax, Valium, Ativan or Klonopin, or muscle relaxants, such as Soma, or alcohol.

In response to these deaths, there has been the sea change in how we prescribe.  We are giving fewer opioids.  We are demanding that opioids provide some sort of functional benefit.  This is on top of the efforts to ensure that there is no abuse or diversion.  Patients who have been on high doses in the past respond differently.  Some understand the problem and agree to the decrease.  I find that these patients do well and do have any decrease in function on the lower doses.  Others object strongly.  Because of concern over patient safety, even when there are objections, we lower the dose.  We do this because we genuinely like our patients and want them to do well.