By Dr. Jeffrey Grolig.

The irrational fear of opioids, opiophobia, has plagued our country before. Prior to 2000, especially in the 1980s and 1990s, opiophobia ruled the medical community. Physicians and pharmacists alike reserved opioids for only cancer and surgery. The fear was that opioids used for more than a short time would cause overdose, death and addiction. The War on Drugs from the Nixon era caused non-opiophobic doctors to be targeted, arrested and disciplined.

But then Dr. Russell Portenoy conducted research showing that chronic pain patients actually did well on these opioids, achieving an excellent quality of life with vanishingly few developing problems. Study after study was published supporting this viewpoint. Dr. David Fishbain found that opioids prescribed to non-addicts rarely resulted in addiction.

Dr. Jeffrey Grolig

But then Dr. Russell Portenoy conducted research showing that chronic pain patients actually did well on these opioids, achieving an excellent quality of life with vanishingly few developing problems. Study after study was published supporting this viewpoint. Dr. David Fishbain found that opioids prescribed to non-addicts rarely resulted in addiction.

Finally the government and the medical community realized that science and not fear should dictate proper prescribing policy. The American Pain Society spoke out and decried that a national epidemic of untreated pain existed in our nation’s hospitals. This led to the adoption of “Pain as the 5th Vital Sign”. In 2001, the Joint Commission mandated that hospitals across the country assess pain in each patient. The Veteran’s Hospital System did the same. Soon the government came fully on board to eliminate the scourge of opiophobia.

The Federation of State Medical Boards, the agency that sets national standards for state medical boards across the country, adopted the 2004 policy on controlled substances. This policy was so opioid friendly that it required all physicians to adequately treat chronic pain, or else risk license discipline. The DEA was unofficially told to “leave them alone” regarding opioid prescribing doctors unless there was blatant drug trafficking.

The pharmaceutical companies jumped on the train as well. They developed potent long-acting opioids that pain patients could conveniently dose at once per day. Over the next two decades, opioid prescriptions skyrocketed by 400%. High schoolers started stealing, using and in some cases selling their parent’s or grandparent’s pills. Greedy physicians built multi-million-dollar pill mills by trading cash for opioid scripts.

And then the music stopped.

In 2013, the Federation of State Medical Boards sounded the alarm that the new scientific studies showed little benefit from long-acting opioids, but a great deal of harm. The FSMB reversed their opioid-friendly rules. They published the new “Model Guidelines on Controlled Substances” which placed numerous burdens and restrictions on their prescribing. Quickly, all 50 state medical boards incorporated some version of these rules into their local guidelines.

The DEA was green-lighted once again to pursue doctors. In 2016, the AMA dropped pain as the 5th vital sign. Opiophobia was once again alive and well. Finally, with a final swift blow in 2016, the CDC delivered the death knell, the infamous “CDC Guidelines on Prescribing Opioids for Chronic Pain”. In an unusual move, an agency that usually deals with communicable diseases like Ebola and Anthrax, and has no training in chronic pain, issued regulatory guidance in an area outside their field. With great understatement, the agency reported that these guidelines were meant only for information, and were not to be legally binding.

But legally binding they have become.

Every major insurance carrier from Medicare to Medicaid now uses these CDC guidelines as a sword to ruthlessly slash opioid prescribing. Today, opiophobia has reached epidemic proportions and has even surpassed the levels seen in the 1980s and 1990s. The CDC has reported an alarming increase in the suicide rate in 2018, citing guns, substances, and puzzlingly not chronic pain.

Today, opiophobia is so widespread that even patients have it. My cancer patient with less than six months to live asked, “Maybe you should make my prescription for fewer pills; I don’t want to get addicted.” The DEA has cut opioid manufacturing quotas by up to 20% across the board. Even injectable pain killers exclusively reserved for hospital use are now in short supply. Now hospitalized cancer and post-op patients are facing inadequate pain control.

The problem we have now is how to reverse the widespread epidemic of opiophobia. We could return to what has traditionally worked in the past; the use of education and science. Science cured our opiophobia in 2001, and it can cure it again today. Let’s return to the studies of Dr. Portenoy, Dr. Fudin, Dr. Fine, Dr. Chow, and Dr. Fishbain. Let’s return to rationality.

They authored the best article on the subject of chronic pain and opioid treatment: “Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain”. It was published in the Journal of Pain in February of 2009. It advises the use of opioids, even above the CDC guideline limits, in selected pain patients with selected diagnoses. In my book, The Physician Primer; Prescribe Like a Lawyer, I rely on this article, authored by a panel of 21 national experts in the field of chronic pain.

My nickname for the study is “Fast Food and Fine Chow”. If every physician read my primer: Prescribe Like a Lawyer, and they practiced by it, opiophobia could be eradicated. Let’s make opiophobia a thing of the past, like polio or smallpox.

For more information, please refer to www.ThePhysicianPrimer.com.

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