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During the last couple of decades, complaining about pain to your doctor was essentially a guarantee you would walk away with a prescription for an opioid painkiller, including heavy-hitters such as Vicodin, OxyContin and Percocet.
This rampant overprescribing is at last beginning to ebb as we’ve awakened to its dangers—namely, addiction, record overdoses and diversion to recreational use. Still, even in the midst of our acknowledged prescription drug epidemic, it remains all too common for, say, a teen to come home from wisdom teeth extraction not with a few extra-strength aspirin but a bottle of hydrocodone.
So what’s a patient to do when they’re on the receiving end of an opioid painkiller prescription? Talk. It may not feel natural to question your caregiver—they are the one with the medical degree after all—but healthy skepticism is in order when opioids are recommended. Here are five vital questions and the reasons for asking them:
1. Why are you prescribing an opioid?
You’re not just looking for medical explanations here; you’re trying to make sure your caregiver isn’t pulling out the big guns simply because they think you want them. Disturbingly, this often appears to be the case. A recent study, for example, underscored the fact that ER doctors commonly report fearing their patient satisfaction scores will suffer if they don’t offer what appears to be maximum relief in the form of opioids—and those patient satisfaction scores are often tied to funding for their medical facility and to performance reviews. (It is worth noting the study concluded that patients actually did not link getting opioid painkillers with satisfaction; they were much more concerned with wait times and physician and nurse communication.)
The same can hold true in the doctor’s office, where caregivers are often pressured to move patients in and out quickly, without much time to get to the root cause of the pain. Prescribing a painkiller can be a quick way to address the issue and signal that pain is being taken seriously. Patients, for their part, have come to feel short-changed if they leave a doctor’s office empty-handed. It’s a bad combination. So as you ask “why?”, it’s important you let your doctor know you aren’t looking for the quickest route to relief but the one that offers the most benefit for the least risk.
2. What are the risks for me?
Never forget that opioids are powerful stuff, activating the same brain centers as heroin, which is also an opioid. Asking about risks is a must, but the crucial part of the question is “for me.”
For example:
- Do you have a family history of addiction or are you dealing with a mental health issue such as depression? If so, your addiction risk increases.
- Are you a woman of childbearing age? Approach opioids with extreme caution. Opioids are linked to birth defects, and the damage can be done early in the pregnancy, before a woman may know she has conceived. Yet a study found that more than a quarter of women with private insurance and even more who are enrolled in Medicaid filled an opioid pain prescription during 2008-12.
- Do you take other medication or are you a drinker? Opioids may be the wrong choice for you. In combination with other drugs, such as benzodiazepines, or alcohol, they can cause serious side effects or be deadly.
In short, be sure your doctor knows your backstory. It matters.
3. What can I expect?
One thing you can’t expect is for all your pain to go away. Even the most powerful painkillers have limits. Ask your doctor to be upfront about all that you might experience, both good and bad, and what level of pain relief is possible. The important thing is to avoid the mindset that you simply need to take more to give you the relief you’re seeking. That’s how dependence starts.
Also, be sure to understand your exit strategy. How long can you safely take it? Should this be a short-term solution only? It can be easy to get comfortable with opioids, but new rules put strict limits on refills. Our current, deadly heroin epidemic has been fueled largely by those who were prescribed opioids, became dependent and then switched to heroin when their prescription supply was no longer available or because heroin became a cheaper and easier-to-access substitute.
4. What else can I do?
In some cases, opioids may be the best choice. But for some types of pain, other options might work just as well or better, such as physical therapy, behavioral therapy, complementary and alternative medicine, and nonopioid painkillers. It’s up to you to let your doctor know you want to explore options. There’s just one catch: You have to be willing to accept the alternative. For example, you might hear, “Yes, there are better ways to treat your knee pain. You can ice it daily, take up swimming, and lose 30 pounds.” Suddenly, that little pill can start looking pretty good. But remember that while lifestyle changes are hard, they often pay off in better physical and mental health.
5. What’s the scientific evidence that this will help my condition?
At this question, you may not get much of an answer. Just recently, the National Institutes of Health convened a workshop of experts to look at all the scientific evidence surrounding our use of opioids for chronic pain. Problem was, they didn’t find much, and the studies they did find were of generally poor quality. Dr. David Steffens, one of the study authors, put it this way in an interview after the report was published in January 2015: When it comes to long-term pain, "there's no research-based evidence that these medicines are helpful."
The tricky thing, he added, is that opioids can clearly be effective in some cases and for some people, but it’s hard to figure out in advance when use will lead to problems. What is needed—and soon—the report concluded, is more and better research, not only on opioids but on other medications and procedures that might be able to replace or supplement them.
In the meantime, it’s patient beware.
David Sack, M.D., is a psychiatrist, addiction specialist and CEO of Elements Behavioral Health, a nationwide network of addiction and mental health treatment centers that includes Brightwater Landing in Pennsylvania and COPAC in Mississippi.
