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Thursday, October 3, 2019

A Series of Observations on Opioids By a Palliative Doc Who Prescribes A Lot of Opioids But Also Has Questions.

by Drew Rosielle (@drosielle)

Part 1 – Introduction, General Disclaimers, Hand-Wringing, and a Hand-Crafted Graph.

This is the first in a series of several posts about many aspects of my current thinking about opioids, with a focus on how my thinking about opioids has changed over the years.

Opioids, opioids, opioids. The working title of these series of posts was in fact “Goddamned Opioids and the Goddamned Opioid Crisis’ because it’s a confusing time out there. A lot of us in palliative care have watched the unfolding, devastating, opioid overdose crisis in the US with dread and horror, as well as the multitude of responses to it, some of which have been harmful to patients.

But, on the other hand, the reality is my thinking about opioids now, in 2019, is markedly different than it was in 2009. A lot has changed, I’ve changed, and honestly I’m a lot less enthusiastic about opioids’ therapeutic potential for treating pain than I was 10 years ago. I hope to describe those changes and the evolution in my thinking about opioids over the last decade here, and to look at some of the very basic assumptions we make about opioids.

This series of posts is not going to be solely about the overdose crisis and opioid policy. I plan on talking about some of the things I believed early in my career, which I no longer believe to be true – like the preferability of long-acting opioids, opioid equianalgesic tables, opioid ceiling effects, and my thoughts about the current fashion of ‘exempting’ cancer pain and ‘patients receiving palliative care’ from some of the newer guidelines and policies. Hint: I don’t think it’s an unequivocally good thing those groups are carved out.

It should be noted that I know I’m discussing a convoluted and emotional topic, but in order to talk about it one must talk in generalities, so I will talk in generalities. And I just want to say that I will make liberal use of qualifiers like ‘mostly’ or ‘rarely’ and that when I use such qualifiers I am doing it deliberately. Mostly means mostly, not always; rarely means rarely, not never. E.g., if I were to say something like “high dose opioid therapy outside of end-of-life care is rarely helpful,” I in fact mean rarely, and I do not in fact mean never, because I know there are important exceptions, even if I don’t take the time to elaborate all the examples that don’t fit into the generalized statement.

As I’m writing that disclaimer, it strikes me that in fact a lot of what’s wrong with the current policy discussions about opioids is that the at-times-very-well-intentioned policies to restrict access to opioids fundamentally take the tactic of eliminating our ability as clinicians to care for those exceptions (those exceptions being our patients, who are in pain). I.e., a policy takes the fact that post-op opioids are overprescribed (which they absolutely, 100%, are), and the fact that for many surgeries many patients do just fine with, say, 3 days of low dose opioid therapy (also absolutely true), but then policy is created which effectively makes it very difficult for clinicians to adequately treat the minority of patients whose post-op pain course requires higher or longer doses (for example, mandating only 3 days of meds get prescribed post-op, even if they are discharged on a Thursday and if the patient needs more meds on a weekend no one is available who can e-prescribe opioids; or by essentially auditing/scrutinizing/punishing clinicians who prescribe more than than ‘the standard,’ even when it’s completely clinically appropriate and safe, thus discouraging the clinician of appropriately caring for the patient because they are being told from many stakeholders that ‘good care’ is ‘not prescribing a lot of opioids’ instead of the far more nebulous but ‘actual well-being of patients’).

It’s this elimination of our ability to provide individualized care for patients on the rightward end of the long-tail of opioid need that is a major problem so many of us are facing right now.

Read the rest of this series:

Part 1 – Introduction, General Disclaimers, Hand-Wringing, and a Hand-Crafted Graph.
Part 2 – We Were Wrong 20 years Ago, Our Current Response to the Opioid Crisis is Wrong, But We Should Still Be Helping Most of our Long-Term Patients Reduce Their Opioid Doses
Part 3 – Opioids Have Ceiling Effects, High-Doses are Rarely Therapeutic, and Another Hand-Crafted Graph

For more Pallimed posts about opioids.
For more Pallimed posts by Dr Rosielle click here.

Drew Rosielle, MD is a palliative care physician at the University of Minnesota Health in Minnesota. He founded Pallimed in 2005. You can occasionally find him on Twitter at @drosielle.
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