America's opioid epidemic kills, but so does taking away much-needed pain medication
There are unintended consequences of reducing access to pain medication. Withdrawal, depression and pain can cause patients to seek out relief.
Kimberly Buck, a medical colleague of mine, suffered permanent nerve damage a few years ago in her left leg. The resulting daily pain was so severe, it interfered with her ability to work or care for her family. Fortunately, a combination of chiropractic care, physical therapy and occasional anti-inflammatory injections allowed her to be productive.
Then, the pandemic hit and she lost access to vital in-person services. Her leg pain and depression began to worsen until her pain management doctor recommended opioid therapy. Hesitantly, she agreed and found that she was able to resume the lifestyle she had previously enjoyed.
Everything was going well until a few weeks ago when Kimberly developed bronchitis. Although she tested negative for COVID-19, a harsh, persistent cough lingered. Her primary care provider prescribed her a cough syrup with codeine, which helped her get the sleep needed to recover. Since codeine breaks down into morphine, both Kimberly and her primary care provider contacted her pain management doctor to explain the situation. The following week, everything seemed fine during her scheduled pain management appointment.
A harrowing overcorrection
Kimberly told me a nurse called a few days later to tell her that she was being discharged from the practice for testing positive for morphine. Dumbfounded, Kimberly asked the nurse, “Isn’t that from the codeine cough syrup I was prescribed?”
The nurse didn’t know.
Realizing her doctor’s decision to cut her off would cause a return of her leg pain and depression, Kimberly felt panicked, judged and confused. Kimberly asked to speak with her doctor but was told the doctor doesn’t do that and the decision to discharge her had already been made.
Many of my patients have had similar experiences.
One such patient was a giant of a man, standing 6 foot 5 and weighing over 300 pounds. A severe back injury had ended his career as a nurse. Although he missed taking care of patients, he was dependent on prescription opioid therapy just to be able to care for himself. During an office visit to go over his labs and review his medications, he expressed frustration over his pain management doctor requiring him to taper his opioid prescription based on the 2016 Centers for Disease Control and Prevention guidelines.
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He asked me what he could do, and I agreed to refer him to a different pain specialist. Before he was able to get the second opinion, the coroner called to inform me that my patient had been found dead after overdosing in his apartment. Withdrawal, depression and pain had apparently driven him to seek relief from someone other than a doctor. As a nurse, he knew that reducing his prescribed dose of opioids had also reduced his tolerance. He died trying to feel better, and I can’t shake the idea that his pain specialist and I failed him.
Responding to a real crisis
“First, do no harm” is the foundational principle of medicine around the world. But there is increasing evidence that the medical community has unintentionally inflicted harm on people by rushing to dissociate itself from the opioid crisis. Although not every clinic treats people the way my colleague and my patient were treated, abruptly restricting access to compassionate care is common.
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The isolation and emotional distress caused by the pandemic have not been the sole driver of the increase in overdoses and suicides in recent years. These “deaths of despair” have been rising for years.
Starting in the 1990s, physicians had been encouraged, even threatened, to aggressively treat pain with prescription opioids. This led to an epidemic of overprescribing that peaked in 2012, when doctors prescribed enough opioids for every adult in the United States to have their own bottle of pills.
By then, America had an escalating crisis of prescription drug misuse and overdose deaths. Physicians responded by starting to prescribe fewer opioids.
Even as access to prescription opioids declined, there continued to be increases in overdose deaths from 2013 through 2017. Multiple studies, including one released in August involving more than 110,000 patients, have confirmed that instead of decreasing harm to patients, discontinuing prescription opioids could increase illicit drug use, overdose deaths and suicides.
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This unintended consequence must be recognized as contributing to the unprecedented rise in deaths of despair. Even with all the attention and resources we’ve thrown at the opioid crisis, the number of people dying continues to climb, to the point that the U.S. life expectancy is now in decline and trails among peer nations.
Many doctors don't heed warnings from international pain experts and the Department of Health and Human Services (HHS) against forced opioid tapering. The decision to taper opioids should be done collaboratively and compassionately with patients living with chronic suffering from physical pain, unmet mental health needs, or substance use disorder.
Patients discontinuing opioid therapy need greater access to services in a way that feels safe and supportive to the patient, not less. HHS also recommends that physicians consider offering patients being tapered off opioids the overdose reversal medication naloxone, to carry with them.
A significant factor contributing to the rise in deaths of despair among people living with chronic suffering is not whether they have access to prescription drugs, but whether they have access to the compassionate care they desperately need. Forced to suffer, and withdrawal from previously prescribed opioids in isolation, many may turn to illicit drugs with unpredictable doses and effects – like heroin and synthetic opioids – in a desperate attempt to feel better. Others escape their suffering by taking their own life.
Buried in the tragic data coming out about the surging deaths of despair are real people with health care needs who feel abandoned by the health care community. There is a stigma attached to people – and doctors who treat people – with chronic pain, unmet mental health needs and substance use disorder. There is no doubt that prescription opioids have been a significant part of the problem. But the answer can not be to abandon people living with chronic suffering.
Dr. William Cooke is a physician specializing in family medicine, addiction medicine and HIV medicine in Indiana. He is the co-author, with journalist Laura Ungar, of "Canary in the Coal Mine," about working at the epicenter of the national opioid crisis.