Responsible opioid prescribing requires navigating between the Scylla of over-prescribing and the Charybdis of under-prescribing. Clinicians can work toward this goal by initiating prescriptions when (and only when) appropriate, managing them over the long-term, and knowing how to compassionately deprescribe when the time comes.
Lifelong Learning in Clinical Excellence | November 7, 2019 | 4 min read
By Travis Rieder, PhD, Johns Hopkins Berman Institute of Bioethics
Between 1999 and 2010, prescriptions for opioids quadrupled. During that same time, overdose deaths involving prescription opioids quadrupled. Rampant overprescribing helped spark a catastrophic public health crisis.
Unfortunately, a seductive narrative took hold: if supply had been the problem, then restricting supply must be the solution. As a result, an anti-opioid narrative took hold and doctors—who had so recently been told to aggressively treat pain with opioids—were now being told to stop killing their patients. The resulting chilling effect on prescribing, far from solving the emerging overdose crisis, made it worse. As clinicians began to restrict access to opioids, overdose deaths involving heroin—and eventually illicit fentanyl—sharply increased, suggesting that at least some people were willing to replace prescription opioids with their far-more-dangerous street analogues.
The result of this ping-ponging back and forth between aggressive use of prescription opioids and withholding them out of fear is a healthcare system in which patients are both under-medicated (because they might be “drug-seeking” or “malingering”) and over-medicated (written prescriptions for massive amounts of opioids for relatively modest pains). What I have recently argued in my book In Pain is that we must replace the swinging pendulum of attitudes about opioids with a nuanced view of responsible prescribing.
In my view, responsible opioid prescribing has the following three characteristics.
Opioids should be initiated when, and only when, appropriate—and then only in judicious amounts. Although this sounds perfectly commonsensical, it is not universally practiced. We now know that dentists, for instance, were the second-highest prescribers of immediate-release opioids for the first decade of the 21st century, giving out bottles of pills for every tooth extraction. This is a failure both because we now know that most pain from routine extractions responds perfectly well to ibuprofen and acetaminophen, and because even in the case where opioids might be called for, the need is only for a few. The number of pills matters here, because the larger the initial prescription, the higher the likelihood that an opioid-naïve patient will still be on opioids one and three years later.
Although the requirement of appropriate initiation is certainly important, it gets virtually all of the play in discussion of responsible prescribing. We must not prescribe opioids for every little ache, and we can reduce drastically the number of pills that go out into the world. However, there is much more to ethical prescribing. A clinician’s responsibility does not end with her signature on the prescription pad. Rather, clinicians must also consider:
Because it is appropriate to initiate opioids at least some of the time (think, least controversially, of severe traumatic and post-surgical pain), it’s also crucial to ensure that patients who are rightly initiated on opioids don’t needlessly develop dependence, addiction, or eventually overdose. This means educating and counseling opioid therapy patients on proper use of the medication, on the long-term plan for managing their pain, and on an eventual exit strategy. Every patient who goes in for a knee replacement surgery, for instance, needs to know how to manage her pain in the long term, and what the ultimate goal of her opioid therapy is.
Finally, speaking of exit strategies, prescribers must also be concerned with:
My own experience with opioids—which led me to this area of research—revealed a massive gap in the healthcare system: many clinicians either don’t know how, or aren’t willing, to comfortably taper patients off opioids when they are no longer needed. Especially as we become more aggressive in our commitment not to transition acute pain patients into long-term opioid therapy patients, every patient who is put on opioids must be provided with careful and compassionate tapering of those opioids. Dependence can form in as little as a few days of high-dose, around-the-clock opioid therapy, which means that many post-surgical and trauma patients will experience withdrawal symptoms if abruptly discontinued. Prescribers must know this, and know how to avoid the worst of the symptoms. Responsible prescribing includes responsible deprescribing.
My hope is that these requirements seem eminently sensible. However, sensible or not, our current healthcare system, education for clinicians, and culture of stigma surrounding pain and opioid therapy have made living up to them increasingly difficult.
Ethical prescribing does not end with a signature. That’s where it starts. A clinical relationship that includes careful management and deprescribing is part of responsible, compassionate medicine.
Travis N. Rieder, PhD, is a Research Scholar at the Johns Hopkins Berman Institute of Bioethics and author of In Pain: A Bioethicist’s Personal Struggle with Opioids.
Learn more about opioid withdrawal in Dr. Reider’s 14 minute TED Talk: