Physicians cannot control patients' access to illicit non-prescription opioids, nor to prescription opioids obtained from illicit sources. Physicians can restrict access to appropriate doses of a single prescription opioid, in restricted quantities, to reduce the risk of overdose. Overdose with only one prescription opioid found in the blood of the victim, and with no other drugs of abuse, often is not reported, making the percentage of overdose deaths involving patients using only properly-prescribed prescription opioids difficult to infer, according to the CDC. The NIH estimates that "roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them, between 8 and 12 percent develop an opioid use disorder, and an estimated 4 to 6 percent who misuse prescription opioids transition to heroin."
Physicians are frequently called on to treat acute moderate-to-severe pain not relieved by over-the-counter pain medications, but which we know from experience will be at least partly relieved by an opioid medication. We do not know the risk of a given patient ending up as an addict or overdosing if we prescribe an opioid pain medication.
We do not know the risk that denying a prescription opioid pain medication will drive the patient into the hands of criminal drug dealers in an effort to alleviate their pain with illicit opioids. Doctors risk being blamed for the unknown percentage of patients at risk of addiction and overdose, regardless of what we do, regardless of how prevalent opioid abuse may be in a particular practice or community.
The NIH and CDC have prepared a 15-point, 50-page guide to prescribing opioid pain medications more safely, along with a summary fact sheet. In the current crisis of increasing overdose deaths, physicians should read and adhere to these guidelines, despite the increased time and effort required to perform, and document, all of the recommended counselling, anti-drug-abuse contracts, pill counting, urine testing, and other potentially insulting measures. Many pain patients are offended by such enforcement measures, complaining they are made to feel like they are under suspicion.
Unfortunately, doctors and their pain patients will continue to suffer such inconveniences, insults and financial burdens, until the epidemic of opioid overdoses ends.
David L. Keller, MD, FACP, is an internist in Lomita, Calif.