Why doctors prescribe opioids to known opioid abusers

Anna Lembke
New England Journal of Medicine 2012 October 25, 367 (17): 1580-1
Prescription opioid abuse is an epidemic in the United States. In 2010, there were reportedly as many as 2.4 million opioid abusers in this country, and the number of new abusers had increased by 225% between 1992 and 2000. Sixty percent of the opioids that are abused are obtained directly or..

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Madeline O'Connor

Excellent article! I started my medical career taking over for a physician who prescribed opioids for any patient who complained of pain, and I was put in the position of either continuing the prescription, or putting patients into withdrawal. My clinic director could not understand why I needed to spend so much time evaluating these patients to see who did or did not have a problem with addiction.
The author is right to point out that compensation is a big factor. It takes 5 seconds to sign off on a prescription and 30 minutes to screen a patient for misuse of drugs and to plan a strategy to taper painkillers.
From a Canadian perspective, the pressure to maintain high patient satisfaction ratings is not that significant, but the pressure to see more patients in less time is quite overwhelming. The medical schools are highly subsidized by tax dollars, so there physicians are pressured in subtle and not-so-subtle ways to see more patients in less time. Opinion pieces in medical journals regularly complain that female physicians and younger physicians are not working as hard as their older male counterparts. The majority of Canadian physicians are paid a fee per patient, so docs who see more in less time earn more. Being diligent takes time, as well as resourcefulness in billing. I spent many hours learning how to discontinue drugs (we are taught how to start them, but little on stopping them). I began screening my high risk patients for street drugs, and I learned how to treat addiction to opioids using long acting substitutes. Treating chronic pain in patients with addiction remains challenging. People with severe addictions are more likely to get acute injuries and more likely to get chronic complications from their injuries by way of not following through with treatment. Physicians should also be aware that patients receiving treatment for chronic pain may get withdrawal-mediated pain in response to an acute injury (pain seems to be the antidote to opioids).


Ronald Prucha

Weaning an addict off opiates is the easy part...getting the mental health care they need to keep them off is a completely different and frustrating story!


Nikhil Autar

Getting abusers off the drug is a start. But we also have to wonder and fix, in all cases of addiction, the hole they were trying to fill in their lives when they started abusing. And we have to empathise with them, not deride them or think they're not worthy of treatment. Because they're not dissimilar from us. We too are trying to fill our lives with something, be it our careers, our struggles for money, power or fame. The only difference is in how we get it.


sam miley

I became addicted to pain meds in 2005. Every doctor I went to would prescribe anything I asked for when dealing w/ pain. Yet, when I sought a way to detox, nothing but a private rehab was available at 30,000$. Praying addiction will become a "disease" soon for the betterment of all addicts! Great article.


lisa diamond



Steve Novack

Another reasons why docs continue to prescribe to addicts: they're afraid the patient will turn to heroin. That assumes the doc doesn't have another option (i.e. Treatment). That's one of the reasons we started a treat pgm


Joseph Troncale

As the author states, addiction is thought to be less of a priority than pain. In fact, addiction is much more lethal. It is also much easier and financially rewarding to write a prescription than talk to a patient and educate them about their need for treatment of addiction or therapy for their trauma. Addiction treatment is very counterintuitive and poorly taught in residency programs in general. Education of physicians is key, and, as was also stated in the paper, there has to be disincentives for providers to chronically prescribe opiates.


Simon Hulme

This is a growing issue in the UK too. The most challenging patients I see are those with perceived severe and often unexplained pain who start off taking dihydrocodeine and progress to escalating doses of strong opiates. I'm sure that the 'pain' being treated is commonly emotional and psychological distress. Unfortunately somewhere along the journey these patients problems seem to become more addiction related with drug seeking behaviour becoming a predominant feature of their interactions with the health service. We are encouraged to refer patients in whom we are considering strong opiates to secondary care pain services. However these are often nurse led protocol driven clinics where patients are put on increasing doses of morphine or oxycodone which are prescribed by the GP on advice of the 'specialist' service.

In my opinion pain services should have close ties, and make joint assessments of patients, with psychiatric/psychological services and addiction specialists. If not we are on the way to the same crisis situation as the US.


Gary Goodman

Don’t confuse addiction w acute injury or illness that justifies pain Mgt. Receptors for addiction differ in acute events than ones for addiction. Emergency medicine physicians are well aware of chronic users and opioid abusers. Further state databases allow us to track this. I take exception to the remarks slamming Emergency Medicine Physicians as “ones screwing up abilities of other doctors to treat addiction.” All physicians share responsibility in treating patients. The patients also share responsibility in being honest w their providers


Joel Blackburn

Edwin, ER doctors face a constant barrage of drug addicts and when they have 40 patients they don't have time to educate your one single patient. I would suggest you tell your patients not to go to the emergency room when they call and talk to your nurse just because they have pain. Also, JACHO is part of the problem because pain is supposed to be a "vital sign." furthermore, I think that human beings are becoming real wooses and they need to learn to deal with pain instead of always reaching for something to try to eliminate it.


Nigel Norholm

My assumption is that to a large degree drug companies are pushing the "proven results" of opiates and because there is a lot of talk about addiction cessation without any financial support both on the medical staff and the patient end, these numbers will not move without hospitals making a stand similar to the change we have seen in smoking policies over the last 50 years. I just really hope it does not take that long for us to prove how harmful opiates are to the authorities that make these kinds of calls.


Edwin Barron Jr

I would guess the authors comments are double edged by intent . ER Docs liberally prescribing Opiods are a pain in the ass . Such tactics can destroy efforts to treat the patients under my care. If they have CRPS 1 or CRPS 2 , hot. cold, NS or mt or misdiagnosed as fibromyalgia Opiods are contraindicated because their use contributes to hyper sensitization of Glial cell to increase central pain . There are effective drugs for CRPS but they take tim to find the best regimen . An ER Doc really f---- up my efforts to cure the patient when prescribing Opiods. If pain is peripherally activated use a dam ice pack. Mindless prescribing of opiates is anything but compassionate. Chronic pain is a disease not a symptom. Any physician should understand the physiology of pain. I try to help those with CRPS but will not see if they are on opiates. Giving opiates closes the door for diagnosis treatment and cure . You call that compassionate ?


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