Opioid Refugees: Patients Adrift in Search of Pain Relief

LAS VEGAS—Changes in the regulatory and rhetorical climate related to the prescribing of opioid medications has left some chronic pain patients who have legitimate medical needs for these drugs “out in the cold,” pain specialist Steven D. Passik, PhD, said during his PAINWeek 2013 keynote address.

States have passed various laws aimed at preventing opioid abuse, diversion, and overdose, and these laws have provisions such as maximum daily dosages for patients and requirements that providers seek a consultation with a pain specialist if higher dosages are needed. “The unintended consequence is that it's turning doctors away from prescribing [opioids]. It's simply too much of a hassle,” Dr. Passik said.

“This is yet another attempt [by healthcare providers], in my view, to deal with what are actually two complex and interwoven public health crises: pain and prescription opioid abuse,” said Dr. Passik, Director of Clinical Addiction Research and Education at Millennium Laboratories in San Diego, California. “But this is an approach that I think is not as balanced as it could be, and ends up with negative consequences for people with pain.”

AN OPIOID REFUGEE

Dr. Passik told attendees about an elderly breast cancer survivor from Kentucky under his care. She had severe chronic pain from a bad hip and suffered from chronic anxiety disorder. The woman took low doses of opioids and benzodiazepines responsibly, Dr. Passik said, but “sort of fell through the cracks and was dismissed from a practice that decided that it couldn't comply with the law in Kentucky.” The patient faced a possibly mastectomy, yet she was more concerned about pain control post-operatively and even weighed whether she should undergo the operation because of this, Dr. Passik related.

“Can you imagine somebody who's worried not just about their cancer relapsing but worrying about whether or not they'll be able to be treated for pain?” Dr. Passik asked. Noting that approximately 80% of opioid overdose deaths are in non-pain patients, he stated that increasing restrictions on opioid prescribing do not necessarily have an effect on the problem of opioid abuse in the pain management setting. “The continued focus [of legislation] on pain treatment alone is not going to get us to where we want to be in terms of better outcomes on a public health level,” he said. Fewer prescription drug overdoses may result in fewer opioid prescriptions, but “that doesn't mean the problem of addiction is going to disappear, it doesn't mean that the problem of opioid overdoses in general will disappear,” he said.

TURNING TO HEROIN

In places where the population is now unable to get prescription opioids as readily or cheaply as in the past, people have turned to other drugs such as heroin, Dr. Passik said. Indiana, Kentucky, and other places where prescription opioids have become more difficult to obtain have experienced recent surges in heroin use, he said.

For years, pain specialists have discussed a risk-management approach to pain control whereby patients are assessed, monitored, and treated based on their risk for drug abuse if exposed to opioids, but “providers don't always have the time or resources to implement this approach,” Dr. Passik said.

COMMUNITY APPROACH NEEDED

Balancing the need for legitimate pain patients to receive opioids against the risk of opioid abuse and overdose requires a community approach, exemplified by Project Lazarus in a rural North Carolina, Dr. Passik said. [To be presented Thursday] This part of North Carolina has a problem of prescription opioid abuse and misuse higher than the national average. Since the launch of the project, overdoses have been reduced substantially without negatively impacting legitimate pain treatment, he said. “It had to be a community-based approach that went far beyond just a law that made it harder for the pain doctors to prescribe,” he said.

Dr. Passik added: “If we want to get serious about the problems of [prescription opioid] addiction and overdose and serious about the problems of drug abuse, we don't need to do it at the expense of people with pain. At the end of the day, we all have to do our part. I don't think that making the decision that ‘my practice would be easier if I just stopped prescribing pain medications' is the way to go about it. I think the only way to go about it is, everyone has to do their piece: Take care of the patient with pain who you think you can take care of given your resources and time and continue to advocate for people to get access to more complex care somewhere if they need it.”