George Comerci, MD

There is growing evidence that liberal prescribing of opioid analgesics by clinicians for patients suffering from chronic pain may have contributed to the current epidemic of prescription opioid abuse.

Now, University of New Mexico pain management experts warn of a growing backlash among physicians, nurse practitioners and physician assistants in which they refuse to prescribe opioid painkillers at all.

“The increase in opioid-related mortality fueled by injudicious prescribing and increasing illicit use of both prescription and illegal opioids has led some clinicians to simplify their lives by discontinuing prescribing opioid analgesics,” the authors write in a Perspective piece published in the February 20, 2018, issue of The New England Journal of Medicine.

“The fallout from those decisions is a growing pool of patients who are forced to navigate their transition off prescribed opioids, often with little or no assistance or guidance, with the potential for disastrous results.”

The paper was co-authored by George Comerci Jr., MD, Joanna Katzman, MD, both of the UNM Pain Consultation and Treatment Center, and Daniel Duhigg, DO, with Presbyterian Healthcare Services in Albuquerque.

The authors acknowledge that more intense scrutiny from law enforcement, professional licensing boards and insurers has caused many clinicians to decide “that prescribing opioids is too high-risk.”

But a blanket refusal to prescribe opioids at all “will increase patient suffering,” they write. “Furthermore, the worst-case scenario is for patients to obtain prescription opioids illegally and eventually transition to more dangerous drugs such as heroin.”

The authors recommend that physicians and other prescribers gain specialized knowledge in managing chronic pain by taking pain management courses. They also suggest transitioning certain patients from risky opioids to buprenorphine, a safer drug that could potentially reduce the risk for overdose death.

Prescribers can adopt strategies to prevent the development of opioid use disorder, such as periodic urine drug screening and patient education. And they can undergo the required training to obtain a special waiver on their DEA license so they can use buprenorphine to treat opioid use disorder.

Opioid painkillers have serious consequences when used improperly, the authors conclude. “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 from injudicious policies.”