The popularity of opioid analgesics for pain has plummeted as judged by healthcare providers on the front lines of prescribing. A large survey of primary care providers published in JAMA Internal Medicine found that many doctors are now reluctant to prescribe opioids for pain. They worry about addiction and side effects in their patients, yes, but they also fear prosecution and losing their licenses to prescribe.
Although some “adverse events” listed by the survey takers are actually expected clinical outcomes with opioids (i.e., tolerance, physical dependence), in a larger sense, the concerns expressed with opioids are well placed. Opioids are powerful agents that can be addictive or deadly in the wrong hands.
Results of the survey show huge majorities of the over 500 practicing U.S. internists, family physicians and general practitioners surveyed think opioid abuse is quite problematic in the community (90%) and that opioids are overprescribed (85%). This is true but only partially.
A closer look reveals a dichotomy: On the one hand, a glut of opioids, particularly for post-surgical and dental pain, results from over generous prescribing that happens when a patient receives a 30-day supply of opioids, a typical quantity, although the pain may be gone far sooner, leaving leftover medication now available to divert.
On the other hand, people are struggling to be treated. Numerous reports are surfacing that more regulatory actions targeting opioid prescribing have led to more cases in which legitimate patients with ongoing severe chronic pain conditions have been unable to fill their prescriptions.
An especially telling result from the survey is that nearly half (45%) of the respondents are less likely to prescribe opioids than they were a year ago. This accords well with the percentage (close to half) that moderately or strongly fear malpractice claims, prosecution or censure by a medical board.
High-profile prosecutions, such as that of Iowa pain physician Daniel Baldi, D.O., accused and eventually cleared of involuntary manslaughter and nine counts of criminal wrongdoing, have likely not gone unnoticed. Though testimony indicated the decedents died from a variety of causes, including deteriorating medical conditions, the use of medications not prescribed by Baldi and the abuse of illicit substances, no medical professional could be blamed for fearing the professional and medical devastation that would follow being targeted for prosecution.
Still, it is beneficial that physicians and other healthcare providers understand the significant risks involved in using opioids to treat pain, particularly long term, and in that regard, these results are welcome. I ask only that a follow-up survey be designed to answer this question: Are legitimate pain patients being denied a standard of care to which they are entitled because of fear in the medical community? Then we will get the complete picture of opioid-related harm.
There is a chasm of difference between appropriate concern and hysterical fear.
Dr. Lynn Webster is the past president of the American Academy of Pain Medicine and Vice President of Scientific Affairs for PRA Health Sciences.
To learn more about Dr. Webster and his work, please visit http://www.lynnwebstermd.com/