Many patients and clinicians have strong feelings about opioids: they’ve seen a loved one denied adequate pain control, or they’ve seen a family member or friend’s son or daughter lost to prescription pill and/or heroin addiction, or they’ve worked in an ED with too many drug-seeking patients, or they’ve seen a patient in terrible pain waiting for a new analgesic order from an unavailable or uncompassionate physician.
But feelings don’t solve complex problems, and an excessively punitive or permissive approach can do more damage than good. Recently, there have been almost daily headlines and policy recommendations about the importance of restricting opioid-prescribing practices. The trend is alarming a number of clinicians with expertise in working with patients in pain. Clinical nurse specialist and pain management consultant Carol Curtiss addresses what’s at stake in “I’m Worried About People in Pain,” the Viewpoint essay in the January issue of AJN:
According to a 2011 Institute of Medicine report, chronic pain is a public health crisis . . . Well-intended efforts to address prescription drug abuse—another public health crisis—may place heavy burdens on people with pain who benefit from opioids and use them responsibly as part of a comprehensive treatment plan. . . . Gains made in pain treatment are at risk. New regulations threaten access to opioids for people with pain.
The essay details other unintended consequences resulting from a host of new or proposed regulations about opioid prescribing, including stigmatization of patients at times when they are most vulnerable and unrealistic regulatory burdens on clinicians, leading some to avoid prescribing opioids even when they are clearly indicated.
No ‘quick fix.’ No one denies that a subset of patients use prescription opioids inappropriately, or that a subset of clinicians and clinics in certain states prescribed for personal gain or in a spirit of recklessness. According to Curtiss, there’s much that can be done or is already being done to mitigate such concerns:
Controlling prescription drug abuse is critical, as is improved access to mental health and addiction treatments. But there is no “quick fix” for these complex problems. State prescription drug monitoring programs must collaborate to make databases available to clinicians across state lines. Prior authorization processes must be more efficient and more transparent. Clinicians should follow current guidelines that recommend comprehensive assessment and ongoing screening before and during opioid therapy; initiating opioids after risk–benefit analysis and as part of an individualized plan; measurable treatment goals, etc. . . .
But, says Curtiss, “denying or making access to pain medications more difficult for people with pain is not the solution.”
Curtiss reminds nurses that “