Back and Forth… and Back Again

The opioid pendulum probably has been swinging back and forth for thousands of years. How incredibly polarized opinions about opioids has been at various points in time—from “They are a gift from god” to “They are the devil personified.” And whenever I speak on it, I’ve started virtually every talk for 30 years showing a pendulum. Where one end of the pendulum is opiophobia, the other end is opiophilia, and somewhere in the middle is something approaching some kind of a balance. The two poles are rather extreme, and I think we went to opiophilia, increased opioid prescribing, 400% and 500%. Ironically enough, a lot of the tools that we need are all around, and it could be one of the safer times to prescribe an opioid if you had the reimbursement time and training to use them all. That’s an irony, because now we basically decided that opioids are too risky, and no benefits accrue from the exposures. It’s been sort of really insidious, the undermining of the idea that anybody benefits. When I talk about the balance, and I’ve been talking about this for years, I talk about applying the principles of addiction medicine as appropriate to the individual patient and all of that kind of thing. If people are going to prescribe controlled substances for any purposes—anxiety, pain, sleep, you name it—that they also have to know enough addiction medicine to be able to do a risk assessment: do the risks of an opioid exposure compare favorably to the benefits that are likely to accrue. Do clinicians know enough about techniques to control the risk that exists? Do they know enough about how to recognize the warning signs that things are going badly and intervene? And importantly, also do they know how to stop the therapy in a humane way?