Although many patients have abused opioids, but it is wrong to categorically label all patients taking chronic opioids as addicted.
Finally, I think it is a mistake that patients doing well on “acceptable,” stable doses of opioids have, in many cases, had these medications withdrawn entirely.13
The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain was misconstrued by insurance companies and physicians (myself included) as a mandate to aggressively reduce opioid doses.10 The U.S. Department of Health and Human Services issued subsequent clarification: “More judicious opioid analgesic prescribing can benefit individual patients as well as public health when opioid analgesic use is limited to situations where benefits of opioids are likely to outweigh risks.”15
Nonetheless, it has become common practice for doctors assuming care of these patients to withdraw them completely from opioids. “The fact that someone has been taking opioids for years does not mean the person has opioid use disorder, but many people make that stigma-driven assumption.”16
The CDC and the FDA have described legacy patients who were started on chronic opioids years ago when the treatment was considered medically appropriate. How should these patients be treated when pain clinics close, or their physicians relocate or retire?17 Finding fault with patients for taking medications prescribed by their physicians is not appropriate; nor is regarding every patient taking opioids an addict.
Thoughtful opinion pieces have appeared in major journals taking issue with “an all-or-nothing approach to pain management.” A perspective piece in the New England Journal of Medicine opined that “as the pendulum swings from liberal opioid prescribing to a more rational, measured, and safer approach, we can strive to ensure that it doesn’t swing too far, leaving patients suffering as the result of injudicious policies.”18
Many negative outcomes have occurred as a result of tapering and discontinuing opioid therapy for chronic pain.
We have seen such drastic change before, when post-menopausal estrogen therapy was dramatically curtailed after data showed that continuous Prempro therapy increased the risk for breast cancer. Almost overnight, estrogen replacement therapy was virtually abandoned, even regimens for which an increase in breast cancer had not been demonstrated.
Forty-two years after receiving my medical degree, it seems to me that the medical community finds it difficult to recognize Aristotle’s maxim that “the virtue in all things lies in a mean between two extremes.” Very few therapeutic decisions are fundamentally binary.
