Speak Out Rheum: How Did We Go So Wrong with Opioid Prescribing?

I have been listening to The Fighter Pilot Podcast because my fantasy career would have been to fly a jet fighter plane (not even remotely possible, given my constitution). I learned that when an aircraft accident occurs, a mishap board is convened, not to assign blame but to try to learn what went wrong and avoid another mishap.

We should apply the same process to medical practices that were once considered good medical practice, but later were deemed undesirable. The liberal prescribing of high-dose chronic opioids is a good example.

When I began medical school in 1976, many things we now take for granted did not yet exist: computerized tomography and magnetic resonance imaging scans, effective medications for peptic ulcer disease and viral hepatitis, laparoscopic surgery, monoclonal antibody therapies, third-generation cephalosporins, the diagnosis of human immunodeficiency virus and its therapies, and on and on.

The chronic administration of opioid pain relievers would also be on that list. In the fullness of time, we have all realized that prescribing opioids over the long term in high doses for chronic pain was a bad idea. I have given a lot of thought to the question of how We—the medical profession and society in general—could have gotten this so wrong.

Blaming pharmaceutical companies for what happened is very much in vogue, and no doubt they deserve some of that opprobrium. However, in my view, that is a vast oversimplification of what happened. Although I recognize that physicians are unconsciously influenced by the pharmaceutical industry, I believe those of us who prescribed chronic opioids did so because we thought we were acting in the best interests of our patients.

A Complicated Situation

What follows is my personal recollection of how this complicated situation evolved over several decades. I think it is critical that those trained in the past 10 years or so understand how this story unfolded: “What were they thinking?”

Before and during medical school, I understood that administration of opioids for short courses was appropriate for post-surgical pain or trauma. As a teen, I had several painful kidney surgeries and learned that a shot of meperidine could dramatically relieve severe pain within a few minutes.

My first encounter with chronic use by a patient was in the fall of 1980, during my medical internship. A slight, elderly lady with advanced multiple myeloma was hospitalized under my care; her oncologist had prescribed methadone for severe bone pain. One morning when we could not awaken her, we realized that her methadone levels had accumulated to toxic levels. After we administered naloxone, she woke up, and this sweet little old lady briefly became a raving maniac.