The pendulum on pain control seems to be starting to swing back. If you’ve been in practice for 15 years or more, you know what this means. The movement telling physicians all pain is avoidable and "deserves" treatment with small, medium or high doses of opioids – whatever it takes – appears to be on the wane.
Although I suggest physicians obtain medical information from the New England Journal of Medicine, perhaps some of you saw the Dec. 12, 2012, weekend edition of the Wall Street Journal. In an article from that edition, physician proponents of nearly limitless opioid prescribing now acknowledge that for the past 15-20 years we have been overprescribing for many patients.
This has resulted in significant harm. Drug overdose deaths increased to a record 38,329 in 2010, more than motor vehicle deaths for two years running. Most of these deaths resulted from prescription opioids.
This is such a problem that a recent Annals of Internal Medicine includes an article and editorial advocating access to naloxone for nonmedical settings to treat opioid overdose. This opioid prescribing frenzy has occurred, mind you, in the absence of any prospective studies demonstrating statistically significant difference in outcomes.
There is no good evidence that demonstrates improved outcomes in back pain with opioids, and opioids make almost all headaches worse. No sources I could find recommend opioids in the treatment of fibromyalgia. For acute pain, I can say there is nothing better than hydromorphone, having been on the receiving end of it for an acute abdomen.
Going forward, I strongly recommend a reading of the New England Journal of Medicine editorial of Oct. 25, 2012, by Dr. Anna Lembke. Also be sure to use our state’s INSPECT website. (Learn more about the Indiana Scheduled Prescription Electronic Collection and Tracking or INSPECT program in the last issue of ISMA Reports.)
Certainly, there are patients for whom a comfortable life is possible only through chronic opioid use, but I suspect that it is a fraction of those who insist they must have the opioids. To paraphrase one of our colleagues from the past, the aggressive prescribing of opioids was a beautiful theory slain by an ugly fact.