The stigma of the opioid class of medications

I’d like to start by reviewing a recent encounter between two patients. The encounter is real, just a slight variation to maintain anonymity.

Patient 1: I fell and hurt my wrist 4 months ago and I originally had an xray that made it seem like everything was ok, but now after 4 months and an orthopedic evaluation I just found out that I may have a slight fracture after all and I may even require surgery. Meanwhile my wrist is killing me. I started with over the counter medications and they just don’t help. My doctor wrote a prescription for Naproxen but it hurt my stomach more than it was helpful.

Patient 2: Did you try anything like Percocet for the pain?

Patient 1: I asked my doctor about that but he refused to write a prescription. He thought that it was too risky and was worried about me becoming addicted.

Patient 2: That’s just wrong. You need to find another doctor.

Important things to know about patient 1: He is not a smoker. He has no history of addiction, nor does he have any family history of addiction or alcohol abuse of any sort.

How common is this scenario? The answer is more common than you would think. In my own practice, some of the physicians I work with rarely if ever write a prescription for an opioid containing medication. Why is this? There are multiple reasons.

1. Drug Seekers. Some patients are drug seekers. But this is not the norm. Every patient one treats with an opioid medication is a judgment call. If it’s a first time visit and they are asking for high doses of a specific opioid medication, then it might be an issue. Of course one can prescribe a limited quantity until they provide previous medical records supporting their medical history, or provide contacts for previous physicians. One can provide drug contracts in which the patient documents that they will only receive opioid medications from one physician
2. Fear of Malpractice / Loss of Licensure. As with everything in medicine, documentation is key. The DEA is watching, and knows the quantity of narcotics a doctor is writing for. But these are medications approved by the FDA. One must specifically dictate what medication is given, why, how much, review the potential side effects, and list the pertinent history of the patient including any addictive issues
3. Fear of Side Effects. The opioid class of medications has many serious reactions including: dependency, withdrawal with abrupt cessation, low blood pressure, respiratory depression, and seizures as well as more common reactions such as dizziness, sedation, nausea, vomiting, and constipation. As long as these side effects are reviewed appropriately and the patient is aware, the doctor and patient can make a decision together whether or not to try an opioid medication
4. Lack of Education. Pain management is a field in its infancy. Many primary care physicians may not have had proper exposure to the opioid class of medications during their training, and thus are not comfortable prescribing them in general

The encounter noted between the two patients is not uncommon. Pain is real and patients deserve a chance at better control. Often achieving complete pain relief is not possible, but obtaining a significant improvement in overall quality of life is. Prescribing opioids is not a crime, but must be done with respect and understanding of the patient’s situation each and every time.