Posted: 10/11/2018

Opiate addiction is a serious problem that has been responsible for tens of thousands of deaths in this country. Pharmaceutical companies like Purdue, profiting from the sale of massive quantities of opiates, had launched aggressive marketing campaigns to convince physicians (like my self at the time) that opiate addiction was unlikely as long as you were treating pain and that there was no maximum dose. We were taught to increase the dose until pain was relieved. The country was flooded with oxycodone. Addicts, both self inflicted and iatrogenic, eventually lined up at “pill mills” where crooked doctors sold prescriptions for cash and many millions of doses disappeared into the black market.

It was imperative that the system that fed this poisoning of Americans had to change. A variety of control measures were belatedly implemented and physicians got the message that having loose standards for prescribing opiates was not only feeding the illegal market and promoting addiction and deaths from overdoses, it was creating a liability risk for the physician whose name was on the pill bottle when a patient overdosed. Emergency department (ED) physicians, who were a major target of drug seekers, became more and more reluctant to prescribe opiates and many emergency physicians and EDs established a “no opiates” policy that kept the addicts away and freed them of determining who really needed an opiate and who was a scammer.

But have they gone too far?

Now for a personal story: I recently accompanied my wife to an urgent care center affiliated with a local hospital in Asheville, North Carolina because she was having severe sciatic pain. About five years ago she had back surgery for right-sided sciatic pain (excision of a synovial cyst at L4-5). The surgery immediately relieved the pain but it returned about a month ago and became progressively worse to the point that she was literally frozen with sciatic pain “like someone was twisting the bone and breaking my leg”; at times she was literally unable to walk or move. She could not tolerate NSAIDs and acetaminophen did nothing for the pain.

An MRI showed severe spinal stenosis with narrowing of the right L4-5 foramen. She made an appointment to see her neurosurgeon but had an immediate problem: her surgeon was in Miami, where we previously lived, and we were in North Carolina for the summer. What’s more, we were scheduled to fly in a week to a good friend’s daughter’s wedding and we would not be returning to Florida for another 3 weeks. Given the circumstances, I felt that the best course of action was short-term symptomatic pain relief to enable travel pending evaluation for definitive therapy.

Knowing that many facilities have discontinued prescription of opiates and my belief that a short course of an oral opiate was indicated, I called an urgent care center to find out if they had a policy that would prevent the physician from ordering an opiate. I was told that was not the case but unfortunately, I was misinformed. The physician, after performing an appropriate history and physical exam, notified us that it was his policy, and that of the center, that they did not prescribe opiates for “back and sciatic pain.” The physician offered prednisone, Valium, and Prilosec but no analgesic. I told him I felt this was inappropriate since the reason my wife was seeking help was for short-term relief from severe pain with a clearly identified source and a plan for definitive treatment. This was not a case, I said, of using an opiate for chronic back pain, a practice that I would consider inappropriate. And I don’t think we looked like drug seekers. When I asked him if he would order an opiate if he saw a patient with a kidney stone, he said he would. So why not sciatic pain, which can be just as bad? The answer: “Sorry. We don’t do that.”

Having been on the other side of the desk, I felt strange being in a situation where I was requesting an opiate. I’ve heard all the lines used by drug seekers to convince physicians that they just need “a few pills to tide me over until I can see my doctor at home” and I went out of my way to acknowledge my discomfort at doing this but felt that a fellow physician would recognize that this was not a scam.

So what is wrong with this picture?

Is chiseling a “no opiates” policy in stone a proper way to prevent prescription abuse or is it a cop out designed to make it easy to say no but leaving in the lurch patients suffering from acute pain? Is it so important to protect physicians from pressure by drug seekers that they feel compelled to disregard their patients’ legitimate needs?

The ethics of pain relief

In my opinion a blanket “no opiates” policy that does not allow physician judgment or consideration of the specific clinical situation is inappropriate and that a physician refusing to relieve pain is acting in an unethical manner. Yes, that puts responsibility back on the physician, and this can be uncomfortable when facing a demanding patient. (I know; I’ve been there.) And yes, some patients who will get opiates will abuse them. But simply allowing physicians to use their judgment to prescribe small quantities of opiates to appropriate patients would not fuel the epidemic of addiction and would allow physicians to do their duty to their patients.

Isn’t a basic tenet of medical practice that if you can’t cure a patient at least you should relieve their pain?

I urge facilities and physicians to reconsider if they have swung the pendulum so far away from relieving pain that they flat out refuse to order any opiates . Put yourselves in the place of a patient in pain and decide whether manning the barricades against abuse is right if it means ignoring your patient’s need for relief of a pain that is making life unbearable.

We are admonished to do no harm, but we are also pledged to relieve suffering. I’m sure we can do both.

What do you think?