Opioid Prescription Stigma Has Painful Consequences for Patients

By | 2021-04-06T16:21:03-04:00 February 14th, 2021|12 Comments

Carolyn Concia, NP, was confronted with the larger implications of the crackdown on opioid prescribing when she learned why her friend’s son had died by suicide.

The son could not sleep because he was in significant, chronic pain as a result of injuries from serving in the military in Afghanistan, and he had sought help from a doctor. The provider thought he was a drug seeker and did not prescribe anything that would help relieve his symptoms, and the distraught young man went home and ended his life.

At first, Concia thought this case was an outlier, but she soon discovered there were others throughout the country who were encountering similar problems. People with chronic pain conditions who had taken opioids responsibly for years were suddenly being forced to reduce or taper-off their medications. Others who wanted to continue their opioid prescriptions had difficulty finding providers who would accept them as new patients.

“These people are suffering from withdrawal symptoms as well as an increase in their pain because they are no longer receiving adequate treatment,” said Concia, a private practice geriatric and palliative care nurse practitioner in Oregon. “Patients are confused, scared, and many have lost the ability to function.”

Concia is not alone in her concern for patients who are suffering both physically and psychologically because insurance companies, providers, and governmental organizations are changing opioid prescribing policies.

The Opioid Prescription Paradox

A 2019 study of primary care clinics in Michigan found 40% of the clinics would not accept new patients receiving opioid therapy for pain. In a study published in Pain Management Nursing, researchers conducted interviews and surveys to understand the experiences of people seeking pain relief who had been taking opioids for six months or longer, and the results were sobering.

“We found that many of these patients felt like they were battling a healthcare system that was supposed to be providing help,” said study author Crystal Lederhos Smith, PhD, an assistant research professor in the College of Medicine at Washington State University. “They were not only suffering from chronic pain, but also felt demoralized because they were labeled as drug seekers and bad people.”

The policy changes also are affecting patients in hospitals who are experiencing acute pain, said Maureen Cooney, DNP, FNP-BC, a pain management nurse practitioner at Westchester Medical Center in Valhalla, N.Y. Many states have passed laws limiting opioid prescribing for acute pain at the time of discharge.

Some of these laws limit patients who have never taken opioids to a seven-day supply of these medications. As a result, patients who need refills must follow up with a surgeon or primary care provider.

“Getting an appointment is not always easy, and there are many providers who are not comfortable prescribing opioids,” said Cooney. “This can leave people struggling with pain once they are discharged.”

She has also started seeing an increase in the number of patients who refuse to take opioids because they are afraid of developing opioid use disorder. Cooney often recommends a multimodal analgesia approach to treat pain, which combines analgesics from two or more drug classes. Patients with rib fractures, for example, may benefit from opioids when they are used with a foundation of non-opioid pain medications — and when risks for developing opioid use disorder are assessed.

“Opioids, along with non-opioid medications and non-pharmacological approaches, may be appropriate when pain is high and uncontrolled pain is posing a problem for recovery,” said Cooney, president-elect for the American Society for Pain Management Nursing (ASPMN). “If patients are in too much pain to breathe well, cough, and move the risk of pneumonia and other complications increases.”

Uncovering Misconceptions About Prescription Opioids

Although nurse practitioners specializing in pain management agree the country is confronting an opioid epidemic, researchers like Cathy Carlson, PhD, APRN, FNP-BC, were concerned the statistics were not accurately portraying the problem. Carlson, an associate professor in Northern Illinois University’s School of Nursing, started studying the methods used to calculate statistics such as prescription opioid deaths, and she discovered that many people who die of an overdose have more than one substance in the body.

“They may have died from the effects of a drug other than a prescribed opioid, but it is still marked as a prescription opioid death,” said Carlson, whose findings were recently published in Pain Management Nursing.

Carlson also investigated the claim that prescription opioid overdose deaths continue to escalate and cause the majority of opioid-related deaths. She found illicit opioids are primarily driving the current rise in opioid-related overdose deaths, whereas prescription opioid overdose deaths declined after 2011, with small rises since 2014.

While nurse practitioners like Carlson are supportive of policies that encourage providers to exercise caution when prescribing opioids, they are concerned about guidelines that limit the ability to individualize treatment.

The CDC’s Guideline for Prescribing Opioids for Chronic Pain, which was released in 2016, urged providers to avoid prescribing more than 90 morphine milligram equivalents (MME) per day.

This limit was far below what was needed for one 64-year-old woman who reached out to Concia for help. The woman had suffered complications after multiple surgeries to treat colon cancer, and her doctor had prescribed opioids for several years for her chronic abdominal pain.

“She was a model patient,” Concia said. “She never negotiated for more medication, never doctor-shopped and always used one pharmacy.”

Four years ago, her doctor abruptly stopped prescribing opioids, and since then, the woman had been turned away by multiple providers because she was a chronic pain patient. Her pain had become so severe that she stopped working, rarely left her room and lost her ability to function.

Concia carefully evaluated the case and decided to prescribe a combination of oxycodone and morphine. Concia equipped the woman with a certified letter describing that her patient qualified for opioid pain medication to control symptoms and that she was not at risk of diversion, addiction, misuse, or abuse. This letter could be given to a pharmacist if needed. The woman’s pain significantly decreased after she began taking the medication and she started resuming her activities of daily living.

Opioid Regulations Affecting Children

The crackdown on opioid prescribing also is impacting the pediatric patient population, said Sharon Wrona, DNP, PNP, FAAN, Director of Comprehensive Pain & Palliative Care Services at Nationwide Children’s Hospital in Ohio. She sees patients who benefit from opioids when they are experiencing pain from sickle cell disease, arthritis, muscular dystrophy, or severe accidents, but families are often afraid to let people in the community know about their use of these drugs, said Wrona.

“They also worry that they won’t be able to fill their prescriptions because pharmacies and insurance companies vary in what they allow,” she said.

In Ohio, pediatric patients can leave the hospital with a five-day opioid prescription to treat acute pain, but exceptions may be allowed if a provider deems this necessary. Wrona wrote an extended prescription — with an explanation of why this was necessary — for a patient who had suffered multiple fractures after a car accident, but his pharmacy would not fill the extended prescription.

To help educate federal and state organizations about the implications of the new prescribing regulations, Wrona, who is also immediate past president of ASPMN, testified at an FDA Opioid Policy Steering Committee public hearing in 2018. She discussed the importance of individualized pain management, which includes more insurance coverage for opioids as well other forms of pain management, such as acupuncture and non-opioid pain medications.

Although it may be tempting to vilify the decision-makers who are creating stricter regulations for opioid prescribing, Pain Management Nurse Advocate Marsha Stanton, PhD, RN, believes that many of these leaders may not understand the consequences of the new rules.

“It’s a matter of educating them about what led to the crisis and how we have swung to the other extreme,” said Marsha Stanton, PhD, RN, a member of the ASPMN who has advocated for more individualized opioid prescribing policies. “Generally, they are pretty receptive and want to hear how things have gone awry.”


Take these courses on opioids and pain management:

Responsible Opioid Prescribing, Chronic Pain, and Addiction
(1.5 contact hrs)
The goal of this continuing education program is to provide nurses with information about best practices in the prescribing of controlled substances, including safe and effective prescribing, administering, and dispensing of controlled substances to the patient with chronic pain.

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Characteristics of heroin such as its appearance, chemical structure, administration, metabolism, and mechanism of action are addressed in this continuing education module to elaborate on how the drug elicits such a strong, unique euphoric effect compared to other opioid medications. This includes the identification and treatment of heroin overdose, withdrawal, addiction, and other associated complications of chronic use.

Evidence-Based Approaches to Pain Control
(2.5 contact hrs)
This continuing education module takes a public health approach across the continuum of pain care, which can be accomplished without worsening the opioid crisis. The strategy begins with preventing and effectively treating acute pain while avoiding unnecessary exposure to opioids followed by early identification and effective treatment of chronic pain or opioid use disorder, then preventing morbidity and mortality from “high-impact chronic pain”.

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About the Author:

Heather Stringer
Heather Stringer is a health and science freelance writer based in San Jose, Calif. She has 20 years of writing experience and her work has appeared in publications such as Scientific American, Discover, Proto, Cure, Women and the Monitor on Psychology.

12 Comments

  1. Avatar
    Katheryn Bratz February 22, 2021 at 1:30 pm - Reply

    I was so happy to read your story. I have numerous health issues and have had 39 surgeries. My opiates have been my lifeline for 23 years. Now all my medication has been cut in half and I cannot sleep because of the pain. My day now is getting up and making it to the couch. It’s so wrong that I have to suffer like this. Why can’t they see this. I too have considered suicide. It’s not a fun way to live. So thank you for speaking up!

  2. Avatar
    Janet C. Benson February 28, 2021 at 12:07 am - Reply

    I am a retired RN nearing 70yrs. of age. Currently, I am in good health with no severe pain. Unfortunately, my husband is 70 yrs old and suffers from spinal stenosis in his neck and lower back causing chronic pain. He probably does not take as much of his pain meds as he should to allow travel or family activities for fear of adfiction. I remember early in my career we were careful about giving opioids pain meds. Then came the time when we were told no one should suffer with any pain. Any complaint was to be relieved with pain medication. Now it is even more restrictive than in my early career. It frightens me that I or my loved ones are not going be able to obtain relief due to the restrictions for fear of abuse or these drugs. We must find the middle as there are needs for these drugs!

  3. Avatar
    Sharon Kraft February 28, 2021 at 1:35 am - Reply

    I read every painful sentence of the opioid crisis. Or so they call it. In 2003, my son Brian fell off the roof of a customer of their roofing business. After surgery for a broken back and 3 months in a rehab hospital, Brian was fed opioids all this time. He ended up a paraplegic but learned to awkwardly walk with braces, a cane, and pills for the pain. He moved back home because he could not support his apt or his emotional state while living alone. He was in pain all the time. His father carefully controlled all his meds to give me a sense of peace. I was always afraid he would OD. Then the concern for the “crisis” starting decreasing his meds making his pain worse. Oh, I forgot to say he became schizoaffective. Arguing with the voices, listening to their lies. He lived a horrible life until the a.m. of 3/5/20 when his twin found him on the floor next to his bed. The coroner’s report said it was an accidental OD. In his blood with all of his meds, Fentanyl was found. We will never know how or who got him his Fentanyl laced with who knows what. The family suffers the heat from the “crisis”. The doctors made him a drug addict and then they took it away. They took my son away from a loving family. So who are the victims here? I lost my son because he couldn’t deal with the pain.

  4. Avatar
    Dr. Susan Glodstein February 28, 2021 at 7:40 am - Reply

    The term committed suicide is seen as outdated and stigmatizing. This should not be used in publications or when communicating with or about patients. It is better to say a person died by suicide or ended their life by suicide. Please see resources, Recovery Oriented Language at mhcc.org.au for more information.

    • Sallie Jimenez
      Sallie Jimenez March 9, 2021 at 10:33 am - Reply

      Susan,

      Thank you for making this very important point. I have edited the blog.

  5. Avatar
    G February 28, 2021 at 2:43 pm - Reply

    Reading this article gives me hope that individuals with chronic pain may again get the help they need and were able to access until 2016.
    Medical professionals PLEASE know that so many people with chronic pain are needlessly going through additional suffering, as doctors are unwilling to prescribe the meds they have had in the past.
    Please, please educate other medical professionals to advocate responsible opioid prescribing for all the people who deserve to have help for their pain.
    Thank you.

  6. Avatar
    Sarah Hary February 28, 2021 at 4:21 pm - Reply

    Thank God for you. May your voice be heard on behalf of those of us with chronic pain . I’m 70 hrs old and a three time cancer survivor on an opioid for the past 10 hrs for arthritis &pain subsequent to chemotherapy. Only my opioid allows me to continue my active lifestyle which includes a speedwalking mile of just over 14 minutes. I also lead an exercise class weekly and routinely do 4 hrs of yard work every Saturday. With each refill Express Scripts is making my Dr. jump through more hoops.

  7. Avatar
    Lynn Williams RN BSN March 1, 2021 at 5:25 am - Reply

    We are neglecting to include a viable and non-addictive alternative/combination. Medical cannabis. Why are we not supporting the use of edible cannabis for cancer patients or chronic long term pain? It can reduce the amount of narcotic pain medication required and improve other symptoms. The science in this industry has come a long way in isolating the treating of symptoms.

    • Avatar
      Angela Willis April 7, 2021 at 2:44 pm - Reply

      Unfortunately cannabis doesn’t work for everyone. Those with significant pain get little, if any relief. Also, many patients cannot tolerate the disconnected feeling they get with it & those continuing to work, can’t function using cannabis, but they can function on opioids (contrary to popular believe, chronic pain patients do not experience euphoria with their opioids and the body builds a tolerance rather quickly, therefore, not affecting the person’s ability to safely do their job).

      I agree cannabis should be legalized (federally then every state) — at least medicinal cannabis — but it is certainly not a substitute for opioids. I’m afraid doctors will prescribe even fewer opioids if cannabis is legalized at the federal level (and then each state would also have to legalize it), leaving many pain patients without the option that works for them. Plus, I doubt cannabis would be prescribed for those with acute and surgical pain so many of these patients would continue being denied opioids.

      Many hospitals are only allowing IV Tylenol & NSAIDS (and alternatives like Lyrica, Gabapentin and antidepressants), for surgical pain – even hip replacements! Heck, many hospice patients are even suffering greatly!

      There are already so few doctors willing to prescribe opioids due to fear of the DEA/medical boards/AG’s (there is so much I could tell you about this!). If doctors focused on the documentation (unique at each visit instead of copying it from month to month), and had a plan of care they stayed current with, the DEA would leave them alone as long as they aren’t prescribing opioids with benzo’s, despite the fact patient’s have used both together for decades without a single adverse effect. These are safe when used together, when taken as prescribed, but those who abuse these medications have made it impossible for legit pain patients to receive effective relief.

      They need to do the survey again on the number of doctors who will refuse to take new patients if they are on opioids or even if they have been cut off but their main complaint is pain, because I’m confident it is much higher than previously reported and in some states, it’s much worse! I would love to provide some credible references and information to the editors here! Pain patients need help!!

  8. Avatar
    Alta Hanlon April 7, 2021 at 12:42 am - Reply

    I was at the CDC limit of 90 and doing much better than now at 30 mmE. I no longer have hope…I can’t keep up anymore with my home and it’s depressing me because I know why and can’t do anything about it. This happened after being referred to pain management.

  9. Avatar
    Health Times April 20, 2021 at 5:49 pm - Reply

    Well done, on considering about chronic pain and its stigma.

  10. Avatar
    Mary McDonnell,RN July 5, 2021 at 1:26 pm - Reply

    Thank you, soooo much for this excellent article. I will share with my doctors and nurses and all. Then pray for God to help the people that have not chose to give up. We have lost friends too because these patients are not being treated properly. God bless you and keep doing your great work and teaching others, to do so.

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