Health & Medicine

In pain? Many doctors say opioids are not the answer

Empty medication bottles at Wyckoff's Corner Pharmacy in New York.
Empty medication bottles at Wyckoff's Corner Pharmacy in New York. New York Times file

Those of you who have experienced pain, especially gnawing, chronic pain, know that it affects your happiness, outlook and ability to function.

In the past couple of years, the treatment of chronic pain has undergone an earth-shaking transformation as opioid addiction continues to claim — and ruin — lives.

Many primary care doctors no longer liberally prescribe opioid painkillers such as oxycodone, fentanyl and hydrocodone for back pain, migraines and other chronic conditions. Instead, they are increasingly turning to alternative medications and non-drug options such as acupuncture and physical therapy.

“Most primary care doctors are afraid to do pain management because of the opioid backlash,” says Michael McClelland, a health care attorney in Rocklin and former chief of enforcement for the state Department of Managed Health Care. “Either they don’t prescribe anything, and the patient remains in pain, or they turn them over to pain management specialists so someone else is writing that prescription.”

As a result, McClelland says, “People in genuine pain are going to find it more difficult to get medicine they may well need.”

Anita A., who asked that her full name not be used to protect her family’s privacy, says that happened to her father, Fred, when they moved from Maryland to the Sacramento area in November.

Her father, 78, suffers from back pain that two surgeries did not alleviate. For more than a decade, he took opioid medications under the supervision of pain specialists in Maryland. He has tried “every other medicine,” in addition to acupuncture, nerve block injections and more, but the opioids worked best to control his pain, she says.

“He doesn’t take more than he needs, and he’s not seeking to take more,” Anita says.

But in California, two pain specialists declined to see her father, saying his case was too complex. Finally, a primary care physician referred him to a different pain specialist, who saw him in January, three months after starting the quest.

“It’s frustrating,” Anita says. “You get the sense that they’re looking at everyone as a potential addict.”

A year ago, the Centers for Disease Control and Prevention issued new guidelines for primary care doctors prescribing painkillers for chronic pain, which did not apply to patients receiving active cancer, palliative or end-of-life care. The guidelines recommend doctors first prescribe non-opioid medications, such as ibuprofen and acetaminophen, and urge non-drug treatments such as physical therapy.

When opioids are used for acute pain, such as that caused by injury, the guidelines suggest doctors prescribe the lowest-effective dose for the shortest-possible time — often three days.

In California, a statewide database known as CURES records opioid prescriptions. Last year, Gov. Jerry Brown signed a bill that requires prescribers to check the database to see if their patients have received these drugs from other doctors.

Opioids are highly addictive, and over time patients need higher dosages to achieve the same pain relief because their bodies develop a tolerance to the drugs.

“We don’t have any evidence to support the use of daily opioid therapy beyond about three months for chronic, non-cancer pain,” says Dr. Ramana Naidu, an anesthesiologist and pain management specialist at the UC San Francisco. “All of these individuals who have been on opioids for years and years have been doing so without any support from medical literature and science.”

The opioid addiction crisis has led to a crackdown on prescriptions of drugs such as oxycodone, fentanyl and hydrocodone, particularly for chronic pain patients, who are increasingly given less addictive painkillers along with referrals for acupuncture, physical therapy, massage and even yoga.

As the CDC guidelines recommend, pain specialists are now looking to non-opioid medications plus a variety of non-drug treatments to help patients with chronic pain. These include acupuncture, massage, yoga and visits to pain psychologists.

Liz Helms, president and CEO of the California Chronic Care Coalition, believes some people in chronic pain should be able to get opioids, as long as their use is carefully managed by physicians. She had to rely on them in the past after jaw surgery and again after she snapped her back in November, she says.

“That doctor-patient relationship is key to ensuring that someone stays out of pain so they can function,” Helms says. “To take people off a pain medicine that allows them to work and live with a good quality of life is inexcusable.”

Clearly, there’s disagreement between some doctors and patients on this. If you end up stuck in the middle and in pain, I have a few suggestions:

First, you’ll probably need to accept that drugs, especially opioids, aren’t going to be the cornerstone of your pain management. Be open to other options, whether alternate medications or other therapies.

“It’s harder work. It’s not the quick fix opioids are. But in the long run, they are better for your health,” says Dr. C.Y. Angie Chen, an assistant clinical professor at Stanford Medical School who specializes in addiction medicine.

Second, be honest with your doctor and ask questions. If your doctor wants you to quit opioids, ask her to explain how she plans to taper you off.

And if you haven’t already seen a pain management specialist, request a referral.

Check out the “Pain Management Tools” section of the American Chronic Pain Association’s website at https://theacpa.org for more resources, or call 800-533-3231. Ask about the support groups it sponsors.

You also can call the California Chronic Care Coalition at 916-444-1985 or visit its My Patient Rights website at www.MyPatientRights.org.

Questions for Emily: AskEmily@kff.org. This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California HealthCare Foundation.

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