Thread by @ml_barnett

Today’s non-COVID crisis thread – what in the world should physicians do about opioid prescribing in a post-overdose crisis reality?

In @NEJM today I try to grapple with what I view as myths that lead to under- and overprescribing of opioids

nejm.org/doi/full/10.10…

@NEJM For those that won’t read the whole thread … I talk about how prescribers go to opioids too fast but ALSO how they have inappropriate fear of opioids & stigmatize people treated w/ opioids.

Both extremes are a problem!

These are all my opinions, meant to stimulate discussion

@NEJM Myth 1: Opioids are uniquely powerful medications for pain control.

This feels like it must be true but whenever opioids are rigorously evaluated compared to NSAIDs they almost never outperform, and if they do it’s by a tiny amount.

Opioids are just another option* for pain.

@NEJM *acknowledging their unique side effect profile and risk/benefit for different patients

@NEJM Myth 2: Opioids are particularly effective for acute pain.

There are a lot of holes in the data but for many acute conditions opioids again just don’t outperform other options. This includes dental procedures, renal stones, headache, low back pain.

@NEJM There aren’t many RCTs of opioids vs. other options in surgery, but opioid volume can go WAY down post-op with little difference in pain/satisfaction.

Look at this study from Michigan a few months ago - huge drop in opioid use and scores did not budge 1"

nejm.org/doi/full/10.10…

@NEJM Myth 3: Short courses of opioids carry a negligible risk of long-term use or opioid use disorder-related outcomes

This myth is rapidly dissipating, and maybe going in the opposite direction (see below)

@NEJM But there’s strong evidence that around 1-6% of those prescribed a one-time course of opioids develop long-term use or opioid use disorder.

Some people call that a “low risk” … but it’s not low if 17% of the US had an opioid prescription in 2017

nejm.org/doi/full/10.10…

@NEJM Now to myths that could lead to underprescribing

Myth 4: Long-term opioid therapy has no role in treating chronic pain.

I find lots of misunderstanding here. Chronic pain is very hard to treat. Chronic opioid therapy has many many drawbacks and was oversold for a long time.

@NEJM But chronic opioid therapy is not forbidden! It’s far from a favorite, but often we have few options.

In the pivotal SPACE trial of opioid vs. non-opioids for chronic pain, pain improvement was equivalent in both arms - opioid arm had ⬆️ adverse effects

jamanetwork.com/journals/jama/…

@NEJM And let’s not forget the collateral damage and tragic stigma faced by patients who use chronic opioid therapy.

This has been much discussed and I can’t do it justice here, but I think this myth drives a substantial atmosphere of stigma against patients on opioid therapy

@NEJM Myth 5: The side-effect profile of opioids poses an unacceptable risk

We need opioids - there are just not enough alternatives for pain treatment to ditch them. All medications have side effects and opioids have a bunch. Many patients won’t respond to NSAIDs or can’t take them.

@NEJM In the face of the overdose crisis, it's difficult to remain neutral on the clinical appropriateness of opioid use.

But we must take responsibility for dispelling myths and for understanding the nuances of how to use opioids within appropriate bounds.

@NEJM Opioids should neither be embraced as a cure-all nor shunned as universally dangerous and inappropriate.

Like much of medicine, using opioids well is both an art and a science, requiring clinical judgment, shared decision making, and compassion.

@NEJM In a post-COVID world every other problem seems more remote and less pressing

But we must have open discussion about when, why and how to use opioids effectively rather than the current climate of fear and frustration

I welcome reactions and discussion