The CDC reports that between 1999 and 2016, more than 350,000 people died due to an opioid overdose, inclusive of both prescribed opioids and illicit substances like heroin (1). A key feature of the CDC and other national and state-level public health organizations’ responses to the opioid overdose crisis has been to develop guidelines and prescription tracking tools designed to minimize the prescription of opioids, especially in the setting of chronic non-cancer pain. When you consider that, prior to 2010, it was not unlikely that a medical resident would be taught that they were being “opiophobic,” – that is, overestimating the addiction risk of opioids and subsequently under prescribing them – this sort of approach makes a great deal of sense (2).
However, counterpoints to the opioid epidemic are research findings that indicate that certain populations that seem to be under-prescribed opioids. A 2015 article published in the Journal of the American Medical Association found that black children with appendicitis are less likely to be prescribed opioids than white children with the same diagnosis (3). Disparities in pain management care are frequently related to physicians’ tendencies to underestimate or fail to empathize with patients’ experiences of pain and the way these tendencies are compounded by implicit biases (4).
Findings that suggest that opioids are under-prescribed in certain contexts highlight the nuance needed in responses to the opioid epidemic. It also highlights a potential pitfall to educational approaches that focus heavily on only prescribing opioids to patients who truly need them, as it primes students to worry about drug seeking behavior (2). When chronic pain patients are only heard through this filter, it becomes all too easy to mismanage treatment for pain. While over-prescription of opioids is clearly dangerous and investigation of pain management techniques that do not come with such addiction risks is needed, swinging the pendulum too far towards the under-prescription of opioid analgesics also sets patients up for suboptimal care (5).
More nuanced approaches are needed to ethically respond to complex issues like the opioid epidemic. One way to avoiding swinging between the extremes of over-prescription and under-prescription is to reset the educational focus on compassionate care and incorporating the patient’s expertise of their experiences into healthcare decisions (2). Such an approach would foster recognition of implicit biases and prevent minimizing patients’ experiences of pain, as well as encourage the understanding of sociological factors that frequently underlie addiction, and educate patients about different pain management techniques.
1. CDC. Understanding the Epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html. Published 2017. Accessed August 11, 2018.
2. Webster F, Bremner S, Oosenbrug E, Durant S, McCartney CJ, Katz J. From Opiophobia to Overprescribing: A Critical Scoping Review of Medical Education Training for Chronic Pain. Pain Med. 2017;18(8):1467-1475. doi:10.1093/pm/pnw352
3. Goyal M, Kuppermann N, Cleary S, Teach S, Chamberlain J. Racial Disparities in Pain Management of Children with Appendicitis in Emergency Departments. JAMA Pediatr. 2015;169(11):996-1002. http://dx.doi.org/10.1001/jamapediatrics.2015.1915.
4. Fleegler E, Schechter N. Pain and Prejudice. JAMA Pediatr. 2015;169(11):991-993. http://dx.doi.org/10.1001/jamapediatrics.2015.2284.
5. Fields HL. The Doctor’s Dilemma: Opiate Analgesics and Chronic Pain. Neuron. 2011;69(4):591-594. doi:10.1016/j.neuron.2011.02.001
Michelle Arnold is member of the The University of Arizona College of Medicine – Phoenix, Class of 2022. She received her Bachelor’s degrees in Biochemistry and Spanish from Arizona State University in 2015 and a Master’s degree in Applied Ethics and the Professions (Biomedical and Health Ethics) also from Arizona State University in 2017. She has interests in medical humanities, patient-provider relationships, and improving healthcare for underserved communities.