Why I don’t prescribe opioids for long-term pain:
Opioids—like oxycodone or morphine—have long been used for the treatment of pain. Many patients with chronic pain end up on opioid long-term, prescribed by well-meaning providers. It may seems like opioids are the only thing that makes the pain tolerable. Many patients are frustrated when I share with them my policy of not prescribing opioids long-term. Let me explain why:
You may know about the increased media scrutiny, driven by high-profile deaths from overdoses of prescription opioids. Even if you aren’t a celebrity with drug-fueled parties, the risk of dying is real, with almost 19,000 deaths from prescription opioids in the U.S. in 2014. (1) The majority of deaths (60%) actually occur when patients are taking the doses that their doctor prescribed (as opposed to misusing or abusing the opioids). (2) This lead to the FDA recently mandating that opioids have a “black box warning”—the strongest possible warning a drug can have–for “misuse, abuse, addiction, overdose and death (3). In addition, opioids have the usual side effects of fatigue, sleepiness, constipation, itching, and (of interest to my male patients) even lowered testosterone and erectile dysfunction. Despite all this scary information, many of my patients say they want to take that risk regardless because the pain is so bad.
Which comes to my main point, which is that I don’t prescribe opioids because THEY DO NOT WORK FOR LONG TERM PAIN. Imagine if you drank a six-pack of beer very day—eventually, your body gets used to it, and you need to drink more and more to have the same effect. It’s a similar concept with opioids—you body develops a tolerance so that for the same dose, you get less and less pain relief, but you are still exposed to the side effects (such as the risk of death). Even worse, there’s lots of evidence showing that opioid use can make your body more sensitive to pain. (You can google opioid-induced hyperalgesia.) Imagine now if you had another injury or surgery—and the opioids don’t even work for you, and you’re more sensitive to pain.
It would be quite easy for me to simply prescribe you opioids, increasing the dose over time, and you might be happy for a while—until you reach the end of the road where your body needs dangerous amounts of the drug just to get through the day, but you’re still in pain and miserable, and not living the life you want. There may be other doctors who have a different philosophy than I do, and that is their decision. But for my part, for my patients, my Hippocratic Oath demands that I first do no harm. I absolutely think long-term opioid management is harmful. If you are already on opioids, I will work with you to find other medications so that you can come down on the dose and eventually stop altogether. If you aren’t on opioids, unless you are dying from cancer, I will not start you on it for long-term treatment. Opioids effectively work on the same receptors as heroin. If you came to me for advice, and I suggested that you start taking heroin, you would be right to be skeptical, even if the drug worked temporarily to remove the pain. Just because there’s a brand-name and a pharmaceutical company putting it in a nice pill doesn’t make it any less crazy. There are many other things—physical therapy, other medications, basic and advanced procedures, and lifestyle modification–that we can try, if you’re willing to work together to keep trying.
Thank you for your understanding.