A tough balance for physicians: Limiting opioids, treating patients in pain

Some think new government guidelines on how primary care clinicians should prescribe opioid painkillers leave doctors between a rock and a proverbial hard place.

If they follow the strict guidelines issued Tuesday by the Centers for Disease Control and Prevention (CDC), doctors must limit drugs for patients who come to them in pain. The guidelines advise physicians to prescribe treatments other than opioids for chronic pain outside of active cancer treatment, palliative care and end-of-life care.

The CDC guidelines will impede access to narcotic painkillers by patients who would legitimately benefit from them and drive those already addicted to prescription opioids, and who can no longer get them via prescription, to turn to heroin, writes columnist Jacob Sullum for Reason.com.

Many Americans worry along with Sullum. A poll of Americans taken earlier this month found that while the majority support new prescribing guideline, 55 percent said they worry that it will become too difficult for patients who need pain medications for medical reasons to get the drugs.

In addition to the national guidelines intended to reduce use of the drugs and halt the epidemic of addiction, overdoses and deaths, a growing number of states are enacting laws to limit prescription opioids, according to a report in The New York Times.

Physicians are going to have to balance their new role as enforcer of those drug-limiting policies with their need to care for patients, including those who suffer from chronic pain, the Times said. For instance, in Nebraska, Medicaid patients may soon face limits that have been recommended by a state drug review board.

Robert L. Wergin, M.D., who practices at the rural Milford Family Medical Center, told the newspaper he is trying to taper down use of painkillers in his patients with chronic pain in anticipation of new limits. "I have a patient with inoperable spinal stenosis who needs to be able to keep chopping wood to heat his home," said Wergin, who is also chairman of the board of the American Academy of Family Physicians. "A one-size-fits-all prescription algorithm just doesn't fit him. But I have to comply."

Since primary care physicians write the greatest volume of opioid prescriptions, they will be front and center in the battle. The CDC guidelines are voluntary, but can be expected to affect regulators' judgements, malpractice liability and insurance coverage decisions, writes Sullum.

"As a strategy for reducing opioid-related harm, shrinking the supply by making prescriptions less generous and harder to get sacrifices the lives of current users to protect future users," he says, calling such a trade-off "inherently unethical".

And while Americans worry that people won't be able to get pain medication when they need it, that same poll found one-third of respondents say physicians are mainly responsible for the widespread abuse of prescription painkillers.

To learn more:
- read the New York Times article
- here's the Reason blog


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