A Different Side to the Opioid Crisis

As family physicians, we care for extended families: mothers, fathers, brothers, sisters, etc. That is how many family physicians view their patients. The family link defines who they are to each other, and to the family physician who treats them.

But not every patient is seen this way. Those patients who are taking opioids are often immediately branded as “addicts,” even if they are on opioids for good reason. They need opioids to function when they have documented chronic pain unresponsive to other medications and treatments.

Family physicians will see chronic pain patients first. It is up to them to determine if the pain is legitimate or not. Sometimes this is easy; there is radiographic evidence telling the history of the pain. Sometimes it is not that easy and you only have the patient’s words, your hands, and a pain scale of numbers or faces. Then there is the final element of trust – do you trust the patient?

Some of our colleagues are afraid they will lose their license if they write one more opioid prescription for any patient because of the volumes of press on the opioid crisis. But the government is not looking for the family doctor who has a few patients suffering from chronic pain and may be on opioids long-term. They are looking for those who write excessive numbers of prescriptions, consistently, and have a volume that is out of the ordinary for their area. They are looking for diversion of opioids; they are looking for patterns of behavior that signal a problem that needs to be monitored.

A recent article told the story of a man who had a musculoskeletal condition that caused him debilitating pain. He had exhausted all procedures and other prescription medications. Several years back, his primary care doctor gave him an opioid prescription for his chronic pain. It worked so well that he could get up and do things with his wife. He was almost leading a normal life thanks to opioid therapy. He was no longer depressed and his wife was no longer his caretaker. This prescription changed two lives for the better.

Then the news of the opioid crisis hit. When the man went to his PCP, the physician would not prescribe opioids to him anymore. The physician said, “I am not going to lose my license over prescribing opioids.” The man went home, and within hours the pain returned. The next day it was unbearable. He could not move around or go on walks with his wife, who became his caretaker again. Things continued to spiral downward. One day, the man did not see any reason to go on and ended his life. The cause of death was a self-inflicted gunshot wound; not a drug overdose.

We don’t hear stories of how opioids improve and sometimes, save lives. We hear the stories of people who overdose, by accident or on purpose, by combining opioids with other non- opioid drugs such as cocaine. We hear about the illicit purchase and use of street drugs like heroin to replace opioids. We are all victims of the news we absorb. It has caused many physicians to see patients on opioids through a lens that is only negative.

The CDC recently recognized that the rapid increase in deaths by drug overdose is driven in large part by synthetic opioids produced and sold illegally, including heroin, fentanyl and fentanyl analogs like carfentanil, which is 100 times more potent than fentanyl. This contributes to the damaging press on opioids, even though it is not the fault of a physician.

Though doctors cannot always control how patients use the medication they prescribe, the CDC does outline steps physicians can take in attempt to improve care and reduce risks in the CDC Guideline for Prescribing Opioids for Chronic Pain.1 As osteopathic physicians we have OMT, which could be tried first or in addition to first-line, non-opioid analgesic therapy.

I am not advocating that every patient who is on opioids needs them, nor am I suggesting you start prescribing opioids if you are not comfortable. But, each patient who comes through your door needs something from you that they can’t find anywhere else: compassion, health advice, support, direction. These are just part of what osteopathic physicians offer; a wholistic approach to treating patients.

ACOFP members will see patients on opioids – it is a guarantee. But, will we see them all as addicts, or as someone’s father, brother, mother, sister? If needed, will we help them find a pain clinic or a behavioral health resource? Will we follow up with them to be sure they are getting what they need? Will we treat them in an osteopathic way?

 

Osteopathically Yours,

Duane G. Koehler, DO, FACOFP dist. 2018 - 2019 ACOFP President

REFERENCE:

1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65 (No. RR-1): 1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1