Chronic Pain

Opiates for Chronic Pain


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Disclaimers: While the floodgates have been opened by the government to this use of opiates over the past 10 years (with resulting massive consequences I might add), there are strict guidelines which prescribers and physicians must adhere to.

Do as your doc tells you, in other words. If you don’t, he will get in trouble and go to jail. And you’ll have to find another doctor. You can tell, it’s a touchy subject for a doctor, especially because we keep getting blamed for everything.

Opiates and Chronic Pain

Up until a decade or two ago, chronic (more than three days usage of) opiates had been reserved for end-of-life or cancer situations only. Apparently, a large conference addressing this in Italy I believe said, sure, let’s use them on everyone that wants them. As long as it’s done safely. But, the guidelines in the US were spotty at first. Not any longer.

Through the two national epidemics of opiate misuse and opiate suicide, we have evolved the following set of guidelines that are finally becoming strict, “or else” – doctors lose their licenses, patients die, things like that.

Here are some of the pearls, in no particular order, that protect you from hurting yourself, but protect your right to get opiates for your chronic pain ailment.

First of all, chronic headaches and chronic abdominal pain are the most frowned upon chronic pain in terms of not really justifying chronic opiate use. And I agree.

Generally accepted as acceptable chronic pain for chronic opiate use is chronic low back pain. Also chronic neck pain. Also chronicle limb pain, but less so than back.

Interesting pearls involving pharmacists. While you are supposed to use a single pharmacy and a single prescriber, the prescriber, including nurse practitioners now, can get in a lot of trouble for withholding opiates. Similarly, the pharmacist can get into a lot of trouble for withholding an opiate prescription. It’s called abandonment (and if a pharmacist does so without grounds, they can be subjected to extra continuing education credits; yes, not much of a punishment, so they withhold prescriptions regularly). Unfortunately for the whole system, pharmacists in larger chain pharmacies have corporate breathing down their neck. And corporate wants to get involved in your healthcare as much as it possibly can, of course; no news there. So, corporate is strong arming the pharmacist into getting diagnoses and indications for your care, upswings, down swings. Apparently the pharmacist has made themselves entitled to all of your medical records, whether or not you release it. They simply ask your physician, then strong arm your physician into coughing it up… Holding your prescription hostage in the process. They feel they can and so will deny your prescription if you don’t give them the reason for using it.

Trouble with all this is that many small pharmacies have Pharmacy Techs or even less accessing that information. Those non-pharmacists can go out in the community with all the information on your medical records that they want, and spread it “prn.” So, not a good situation.

I recommend that you demand that a pharmacist have a release to speak to other people about your health care. I recommend that your prescriber have a release to speak to other people about your health care. And both of those releases need to be shared by both parties. If all of the above cannot occur, then people should not be talking about your medical records. These releases are safe guards to minimizing the spread and knowledge of your medical history. Sort of helps at least.

Moving on to a few pearls regarding health patients go from Dr. to Dr. (PA to PA, NP to NP like that) trying to get more and more opiates for chronic pain versus using just one doctor, and behaving. To get opiate prescriptions, patients carry around their medical records as if they are a ticket to ride the Opiate train. Unfortunately, the feds don’t much care about you getting an MRI every year. They more care about you getting modalities like acupuncture and physical therapy monthly, Weekly, every other day even, to lower your opiate demands. They more care about a visit to the anesthesiologist every year or so for injections to lower your opiate demand.

Notice, no mention of surgery as a mandate for lowering opiate requirements. And that makes sense because for many chronic pain syndrome including chronic low back pain, surgery leaves about a third of the patients worse the day than They were before the procedure was done. Not good odds. But the good back surgeon is providing this risk I nformation as full disclosure to the patients considering surgery. So it’s a good system.

So it’s not all just about the imaging anymore that lets you get your opiate.

And all of that is just for maintenance, and to keep maintenance as low as possible, and hopefully lower it over time (which almost never happens). As far as actually going up on your dose after you have been doing well on maintenance, that requires even more. There must be documentation of tissue damage to go up on your dose in fact. Either surgery, or trauma, that is evaluated by physician, are the only justifications for going up on a maintenance dose. And that increase should not last for more than 1 to 2 weeks. No matter what. These are the guidelines.

Another big change. Pharmacies are becoming completely intolerant to “I lost my medication.“ Scenarios like this are simply not acceptable anymore. A police report must be filed. And patients are hesitant to do this because they are getting their own family members and friends in trouble who probably stole their medication. But a police report is required. And even with the police report, many pharmacists simply will not fill a prescription early because of loss of Rx!


There’s much more to this. But, bottom line, opiates have been allowed in non-cancer, non-end-of-life chronic settings since a major conference addressing opiates in chronic pain in Venice decades ago btw. But routine drug screening must be done. Comorbidity must be addressed at all times. And strict compliance to non-opiate medication‘s must be enforced.

And monthly or yearly, things like acupuncture MUST be done to continue them. And tissue damage like surgery or an injury evaluated by physician MUST be done to ever increase your dose from maintenance. And increasing the dose for maintenance can only occur for 1 to 2 weeks. Tops. Then you must go back to your previous maintenance dose, no matter what. If you were still hurting in a week or two back on maintenance, then another evaluation must be done that might allow you to increase your dose for a week. All super strict. All good trends.

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