America’s worsening opioid overdose crisis has challenged doctors to find a way to treat pain with opioids but avoid harming their patients. One go-to strategy for doing so is outlined in the CDC’s Guideline for Prescribing Opioids for Chronic Pain, which essentially calls for stricter prescribing practices so that patients take smaller amounts of these drugs for less time. This approach has appeared to be somewhat successful, as new evidence shows, but others have pointed out a grave downside that’s been overlooked.
In a paper published Friday in JAMA Network Open, a team of researchers at Roswell Park Comprehensive Cancer Center in Buffalo, New York show that “an ultrarestrictive opioid prescribing strategy” was associated with patients taking fewer pills after certain types of surgery. On its face, this sounds like a win for doctors. However, the picture is not so simple, and experts worry that restricting patients’ access to opioids could actually have serious consequences.
The CDC video below illustrates the general thinking that patients who get hooked to legally prescribed drugs eventually move on to heroin or other illicit opioids. This is the thinking that informed the CDC’s restrictive prescription guidelines mentioned above. The problem, however, is that this approach can lead to unseen decreases in patients’ quality of life.
As STAT News reported on Thursday, chronic pain patients are increasingly running into doctors who are hesitant to fill opioid prescriptions, pharmacists who refuse to, and state laws that seek to make these prescriptions more difficult to obtain. For many of these patients, getting cut off from opioids can mean significant reductions in quality of life.
The pressure to sharply curb prescriptions appears to be coming from the top. This summer, then-Attorney General Jeff Sessions blamed over-prescribing doctors for the opioid overdose crisis in the same breath that he blamed sellers of illicit fentanyl, which is largely responsible for recent increases in opioid overdose deaths. Statements like these, as well as the DEA’s focus on doctors who over-prescribe opioids, are placing the brunt of the blame for the national public health crisis on doctors and patients. As a result, chronic pain patients have found their doctors becoming increasingly hesitant to prescribe them the drugs they’ve become accustomed to taking in order to go about their daily lives.
As the new paper shows, there really were marked decreases in the amount of opioids prescribed after certain types of surgery when doctors followed the “ultrarestrictive strategy”: Over one year, doctors prescribed patients no opioids after minimally invasive surgeries and only three days’ worth of pills after more invasive surgeries. The average number of pills prescribed decreased from 43.6 to 12.1 for patients who had a laparotomy; from 38.4 to 1.3 for patients who had minimally invasive surgery; and from 13.9 to 0.2 for patients who had outpatient surgery.
Despite these incredibly low amounts of painkilling drugs, there was no increase in requests for refills, no significant increase in patient-reported pain scores, and no significant change in the number of complications. It’s worth noting, however, that this new study was conducted on postoperative patients, a small percentage of whom do end up using opioids chronically.
Ultimately, the ultrarestrictive strategy is one that appears effective in the short term, but in the long run, it puts doctors’ liability in the forefront at the expense of patients’ well-being. And causing patients unintended physical pain may not be the only consequence of this approach. As a CDC report published in September showed, there’s a strong link between chronic pain and suicide.
And so, even though studies suggest that doctors can help manage pain with minimal opioid use, it’s crucial to note that there are still patients who simply can’t function without treatment for their pain. Doctors and regulators who have become overzealous in an effort to curb drug abuse may be inadvertently causing suffering in people who already have more than their fair share of it.