One of the very first patients I treated after opening my pain practice tested positive for heroin.
It was 2017 and I had just started a clinic focusing on the integrative management of pain patients after over 20 years of practicing as a medical doctor and anesthesiologist.
This patient had traveled to me from several hours away—something that can reflect poorly on a prescriber—but she had a diagnosis of Ehlers-Danlos Syndrome (EDS), a painful connective tissue disorder, and an existing opioid prescription. She was in her thirties and had various comorbidities and pains in different parts of her body.
Back then I thought I knew a lot, but I had only just begun. I believe that if you're doing things properly as a pain doctor, you are continuing to learn throughout your career through evidence-informed practice. It's not just a randomized controlled trial, it's looking at so many other types of evidence, as I should have done in the case of this patient.
I took over her prescription and gave her a small number of pills, but days after collecting her urine sample the results came back positive for heroin. Right then and there, I knew this was a whole other ball game.
I immediately started reaching out to her, using various forms of communication to try to contact her. She never responded to anything, so in early 2018 I ended up firing her as a patient.
I know that some people do resort to street drugs because they can't get their opioid prescription, and withdrawal is a horrible thing, but testing positive for heroin is a huge red flag. We needed to work with her psychiatrist to assess her addiction risk. The whole thing was an awful experience—I felt terrible, but ultimately, I wouldn't be able to take care of her.
I finished my residency in 1994, and for around two years worked in a small hospital's pain clinic, focusing mainly on procedures. While medically managing those patients was a very minor part of my work at the time, my recollection of that period is that we were not typically treating chronic pain with opioids.
I spent quite a few years practicing in the operating room before I opened my own clinic, which was a very steep learning curve. I have Ehlers-Danlos Syndrome, which I was still trying to manage at the time, though I do not view myself as a chronic pain patient.
I have never taken any opioids on any chronic basis—in fact, I've been afraid of them since day one as an anesthesiologist, because within the profession there are extremely high rates of addiction.
Particularly in the early days of my practice, things were not as closely monitored as they are now, and I believe that maybe even I was a little more liberal with prescribing opioids.
I had many patients come to me to take over their opioid prescribing, but with every single one I would have to explain that as I was a solo provider my prescriptions should act as a bridge; I should not be their main source of their medication.
However, for many of my patients nowadays, finding alternatives has become really difficult. Their mobility is often limited, and they're in so much pain, it's hard for them to even get to appointments with other pain physicians.
While I understand the prescription of opioids has been quite the process over the past few decades, I feel the pendulum has swung too far. The opioid crisis is so very real; I know people on every side of this equation. I know people whose children have died due to opioid overdoses, but I don't feel we are individualizing patient care.
In my experience, in the last five years patients in acute situations or who have undergone surgery are not even getting a small amount of a stronger medication, as they may have before the opioid crisis.
I have seen physicians receive calls from their patients in terrible pain, who had undergone surgery that day, but were given nothing other than paracetamol and ibuprofen—despite some studies showing a patient is at higher risk of chronic pain if postoperative pain is poorly controlled.
I don't prescribe opioids very often at all, and believe that for most patients with chronic pain, they are not the right treatment. However, for the small subset for which opioids are the right treatment, it's very difficult to get them. I feel like we've put a blanket "no" on opioids for everyone.
It's complicated because nobody can tell you how much pain you're in. It's a subjective experience, and it doesn't always correlate with the findings on imaging or laboratory testing, which makes it very hard for us to assess.
Furthermore, I do not believe the degree of pain that someone is experiencing is an indicator of whether they should have an opioid prescription. Rather, we should ask: Have other things been tried? What's this person's status like?
For example, the case of an older person going through palliative care is very different to patients I have who are 15-20 years old. Every single time I write a prescription I think: "What does this look like long-term? Is this something that's going to be safe for this person to take on a long-term basis?"
I've had patients as young as 15 years old come to me and on their first visit ask me to fill out their disability paperwork. I feel terrible that these people are suffering, but they come to me for help, and I can't name a single instance in which someone has come to me and I didn't have ideas of something else to try.
For me, the goal is not to have people on disability, sitting at home and taking opioids, but to improve their quality of life and give them quality years, especially with my younger patients.
As a pain management physician, you have to play detective, because if a patient is suffering from addiction or is at high risk of addiction then somebody like me should absolutely not be managing their opioids. They need to be in a setting where they receive comprehensive care.
Every time I write a prescription, it's going under my medical license, my DEA certification, and all the time and work that went into that. I do feel there are a very small number of patients who have made it difficult for the people who are legitimately in pain, and for whom opioids are the best option.
Addiction is a very serious problem, but I don't think we should be treating everyone like they're an addict. In fact, some people are at extremely low risk of becoming addicted to opioids or any other medication—we shouldn't be lumping everyone together.
I think the phrase "war on opioids" is horrible. I understand the sentiment, and that often in our culture we use these catchphrases in order to get a message across, but in my eyes it's not benefiting anyone.
I believe we have so many processes and programs in place to prescribe opioids that are not serving our patients. In my opinion, we need to take time to really understand patients' situations, not race through every person—part of which I believe is down to insurance and a third-party payer system which has created an absolute nightmare for quality care.
When patients have chronic pain, they need to know we're there for them. If a person is in pain and knows that you don't believe them, that makes you feel horrible and can actually increase your levels of pain.
When I was in pain, I was very aware of the fact that when I was under more stress, I had more pain. So we as doctors need to be alleviating people's stress, not creating more.
While I do not believe opioids are the best option in most cases of chronic pain, sometimes they are. And when it is, that person should be able to get that prescription without guilt and these barriers that are so incredibly onerous.
Many of these patients have difficulty accomplishing a lot of everyday tasks and even getting to appointments. We need to balance safety and patient care, not use one brush stroke for everyone.
Dr. Linda Bluestein is an anesthesiologist and integrative pain medicine physician. You can visit her website here.
All views expressed in this article are the author's own.
As told to Newsweek's My Turn associate editor, Monica Greep.
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