'Just Saying No' to Opioids: Not Necessarily Good Medicine

LAS VEGAS—“The war on opioids has resulted in progressively increasing undertreatment of chronic pain,” Michael E. Schatman, PhD, CPE, DASPE, a clinical psychologist and Executive Director of the Foundation for Ethics in Pain Care, Bellevue, Washington, told attendees yesterday.

Despite this “chilling effect,” he said, “there is no virtue associated with merely prescribing opioids to our patients with chronic pain; the heroic physician keeps an open mind, considers his/her patients' well being to be central, and does not let fear of the unknown get in the way of ameliorating suffering.”

He acknowledged chronic opioid therapy is “fraught with problems,” including lack of a long-term evidence basis, the likelihood of addiction—higher than thought—and opioid induced hyperalgesia, endocrinopathy, and mood disorder. Problems with chronic opioid therapy also include abuse, diversion, overdose, and death.

However, “what are our other options?” he asked. Availability of interdisciplinary programs, which represent the strongest evidence-basis for most types of chronic noncancer pain, is waning, numbering now fewer than 100 (outside the Veterans Affairs system), down from more than 1000 in 1998.

For patients with chronic low back pain, for example, options include spinal surgery, which is “vastly overperformed” and for which the evidence- basis is “woefully poor,” and interventional techniques such as epidural steroid injections, for which consensus is lacking, if not contentious, with detractors pointing to lack of training and potential benefits not outweighing potential harms. The bottom line, Dr. Schatman said, is that “interventional techniques are not a panacea for most types of chronic pain.”

A 2010 study found chronic pain was treated by pain specialists (2%) acupuncturists (7%), chiropractors (40%), and primary care providers (52%). However, studies to date on the effects of chiropractic care are equivocal, and it is not without iatrogenesis: cases of vertebrobasilar stroke associated with cervical manipulative therapy have been reported. The efficacy of acupuncture also does not hold up in systematic reviews, he said.

In determining the best patient candidates for chronic opioid therapy, clinicians should review common risk factors for aberrant opioid-related behavior: history of drug abuse, tobacco use, history of DUI, male gender, and age. Risk mitigation includes urine drug testing, “which needs to be utilized regularly and effectively.”

He described the trend toward “narcoterrorism,” a term defined by Dr. Barry Cole to describe regulatory agencies' attack on physicians' efforts to provide relief to their patients through the prescription of opioid analgesics. The result: both physicians and their patients are potential casualties. This war is escalating, he warned, with high-profile cases—some legitimate and some not—going to court.

Dr. Schatman concluded by stating, “what is our only option for practicing pain medicine in a system as perverse as ours?” The answer: to practice from a position of virtue, which means, “to do the right thing rather than that which is convenient.”