The single most important concern in public policy debates related to the use of opioids for persistent, or chronic, pain is what happens to people with persistent pain when they reduce or taper the use of opioids.
Just this morning, a primary care provider came to consult with me, looking for pain rehabilitation options for her patient with a complex set of needs. Emphasizing the legitimacy of the patient’s pain complaints, the provider detailed a long history of an active substance use disorder. The patient has had multiple urine drug screens positive for both opioids, which weren’t prescribed to the patient, and illegal substances. The provider recounts that the patient has been asked to leave multiple pain clinics for similar aberrant prescription drug use behaviors, all of which are indicative of an inability to control the use of opioids. Given the patient's history, she is at high risk of further exacerbating her addiction and/or death, if opioids continue to be prescribed. Nevertheless, the provider feels as if she has to prescribe opioids to the patient because, "she has legitimate medical conditions with real pain."
Opioids, or narcotic pain medications, are commonly thought of as powerful pain relievers. Patients frequently request them and healthcare providers often prescribe them for back pain because they think that opioids are the most effective pain reliving treatment. Popular media and others in society also commonly think that without opioids patients will suffer intolerable or “intractable” back pain. The implication is that, again, opioids are the most powerful and effective pain reliever.
But are they the most effective pain relieving treatment for back pain?
When engaging in long-term opioid management for chronic pain, should healthcare providers discuss with their patients the fact that the medications won’t typically remain effective for the rest of their life? That is to say, should healthcare providers fully review the implications of opioid tolerance prior to beginning long-term opioid management for patients who have chronic pain, but who are neither elderly nor sick with a terminal illness?