Long-term Opioid Therapy Compromises Patients’ Decision-Making Capacity

You read that right folks.

In the latest efforts by anti-opioid zealots and supposed “Addiction Medicine Specialists”, a new opioid-related narrative has been created! According to an article published in JAMA Internal Medicine just last week, led by a certain author who has had way too much influence on chronic pain guidance without having any actual training or expertise in the field, the decision-making capacity of patients on long-term opioid therapy is now compromised.

Are we really going to have to do this?

Without sourcing a single reference to support such a nonsensical statement, these authors have decided to stop shadow boxing and have actually come out of the woodwork with a direct attack on patients with chronic pain who may require chronic opioid therapy as part of their treatment.

My first thought was around the disrespectful nature of the statement itself and the lack of literature cited in the article… It’s safe to presume that the medical and patient community at large would love to know what evidence shows that patients requiring chronic opioid therapy have compromised decision-making capacities regarding their own pain management. Do we say the same thing for patients requiring a SNRI for their diabetic neuropathic pain, or those that require a once yearly ablation for their lower back pain, or what about that patient who requires intermittent celecoxib dosing to keep their osteoarthritis at bay?

Isn’t that all the crux of the argument being made? That, somehow, someway, modalities that allow for pain relief twist the perception that a patient has regarding how substantial that relief is? Or is the argument specific to opioids because of their potential addiction risk?

Who knows? The authors of the JAMA article don’t actually provide any clues as to what they mean by all of this. They, as usual, focus solely on prescription opioids as if we are still living in 2010, a time at which seemingly everyone was prescribed high dose opioids.

We at PainDr are not arguing that opioids are without risks, or that they cannot cause cognitive impairment. Like many centrally-acting drugs, of course they can. There is, indeed, some evidence that shows acute use of opioids can influence decision-making capacity in the short-term. However, we are not aware of a single piece of evidence that shows long-term use ‘compromises’ such decision-making ability… Especially decision-making capacity around a patient’s own pain management.

 

Oh, but that’s not the only derogatory remark made by these supposed ‘experts’.

 

Although patients with chronic pain are not usually at imminent risk of death, they often see no possibility of a satisfying life without a significant and immediate reduction in their pain.

 

Opioid use itself biases patients’ perception of pain relief and weighting of the risks and benefits of ongoing opioid therapy.

 

Pain relief is at maximum at opioid initiation and will likely diminish over time due to development of opioid tolerance.

 

Without surprise, none of these statements are referenced, leaving us all to believe that they are simply made up by the authors. After all, if you’re going to publish a commentary in a journal as ‘prestigious’ as JAMA, you might as well not reference any of the disingenuous statements made with actual evidence-based literature.

What a slap in the face to someone with severe, treatment-resistant rheumatoid arthritis (yes, there are absolutely cases resistant to DMARDs, or whom DMARDs are contraindicated in) who is crippled because of the amount of arthritis and synovitis accumulating in every joint of their body. With chronic opioid therapy, that patient may be able to function at 40% their normal capacity (compared to 10% without opioids). But, no, according to these authors, because the pathology of Rheumatoid Arthritis does not provide an imminent risk of death itself (just crippling and functionally limiting pain), they induce a sense of crisis within themselves and see no possibility of a satisfying life without a significant and immediate reduction in their pain.

This doesn’t just apply to Rheumatoid Arthritis, either. How about the 83 yo patient with multilevel severe DDD, spinal stenosis, multiple disc protrusions, whom otherwise may be a candidate for surgery (though is not because of medical comorbidities), who benefits from long-term opioids that allow them to function and have a quality of life? Or, the 60 yo patient who had to have a right below knee amputation, and now requires the combination of tapentadol, duloxetine, and pregabalin that reduces the pain enough to allow them to use their prosthetic leg, engage with rehabilitation, and allows them to function at 50% the capacity at which they did prior to that amputation?

Are we really trying to say that because these patients require use of a long-term opioid, they are incapable of telling the difference of whether there is actual benefit or not?  Of whether their improvements in functionality are just a made-up perception of their own reality?

And, don’t get us started about the belief that it is a commonality that opioid tolerance leads to diminished pain relief over time. There is actually a substantial amount of evidence that shows just the opposite… That most patients requiring chronic opioids do not require significant opioid dose titrations over time. Even in those who may see diminishing benefit, there may be several underlying factors at play besides just the colloquial term opioid tolerance.

 

Bottom Line:

Our goal here is to not diminish the risk of opioids (of which, like all medications, there are many). We also don’t think opioids are necessary for everyone with chronic pain, and agree with a collaborative, interdisciplinary and multimodality approach to chronic pain treatment. There are times at which the clinician must do what is right for the patient, and, in rare cases, may have to shift some shared decision-making away from the patient. We also don’t agree with just jacking up opioid doses in patients who have diminishing benefit over time and recommend actually evaluating why those benefits may have waned in that individual patient in the first place.

However, we are absolutely and always going to push back on false narratives, and just pure lies, regarding opioid therapeutics.

The thing is, if the authors who wrote such garbage commentaries had actual experience, training, or expertise in treating and caring for patients with chronic pain, they would understand that the vast majority of chronic pain patients want to be more functional (that is almost always their main goal). The vast majority of these patients already have the expectation that their goal quality of life is substantially lower than what it was before they had chronic pain, yet they strive for that lower quality of life anyway. The vast majority understand their pain is not going away and do utilize multimodal approaches to keep the pain as manageable as it can be. The vast majority don’t want to have to rely on any drug, especially opioids, to manage their pain, but often compromise with themselves so that their life and functionality can be improved.

And, maybe, the vast majority of patients with chronic pain have greater perception and understanding of how their chronic pain affects them than any clinician they end up meeting. So, perhaps, we, as clinicians, should listen to these patients more, so that we can help guide them to the goals they want to achieve in safe and appropriate ways; as opposed to dismissing their perceptions because they might require long-term opioid treatment.

 

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