Letter to the Editor
It was with interest and more than a little déjà vu that I read Dr. Graham Walker's article on Dr. Alexis LaPietra's efforts to reduce the use of opioids in her emergency department. (“Managing Pain without Opiates or the Pain Scale,” EMN 2017;39:24; http://bit.ly/2j4yvXW.) Dr. LaPietra's very admirable program appears to consist of using opioids liberally for people in acute pain, but avoiding or limiting their use whenever possible, especially for chronic conditions.
Ironically, this was the way we were taught to use opioids when I trained in the 1970s. This was before we “learned” that pain was a vital sign, that opioids were the only treatment, and that things like addiction and dependency were nonexistent or unimportant. These assertions were supported by uncritical acceptance of flimsy science that was made legitimate by repetition and the failure to resist pressure from zealots and the regulatory bodies they came to influence.
This may sound like nostalgia, but I bring it up because much of the current debate on opioids is characterized by the same type of hype and groupthink that got us into this situation in the first place. Now, we are hearing that opioids are “ineffective,” uniquely dangerous, and inappropriate under virtually all circumstances, and that these drugs can simply be eliminated from our practices or withheld from individual patients without serious consequences.
The slogan, “Vicodin is oral heroin,” has been adopted by the popular press in my locale as revealed truth. Recent articles in the academic literature and popular press imply that any exposure to opioids leads inevitably to addiction, abuse, and overdose. Challenges to this conclusion — based on methodological issues and common experience — tend to be brushed off as pro-opioid heresy.
I applaud the efforts of Dr. LaPietra and her colleagues to re-establish a responsible approach to opioid use, which appears to be evidence-based and judicious while recognizing the complexities of a world in which one treatment is not appropriate for all. If this requires a special program, so be it. In my view, this is simply good, conscientious medical practice. I hope that in the future we can resist the pressure to practice medicine based on public advocacy and soundbite science, and return to a single criterion for the use of opioids or indeed any medical intervention: Is this in the best interest of the patient?
Todd Grant, MD