This is the Opioids Paradox for Chronic Pain Patients


The Opioid Paradox, Lynn R Webster, MD

Our wise elders had a saying: moderation is the key to happiness. Unfortunately, there is little moderation where opioids are concerned. They are both over-prescribed and under-prescribed for patients in chronic pain. This results in what I call the opioids paradox.

Opioids Prescribed In Excess

In fact, opioids sometimes are prescribed in excess. Much, if not most, of the opioid prescriptions (and excess prescriptions) are given in post-trauma situations like ERs, after surgeries for post-op pain, and dentists’ offices; and about 50% of the opioids prescribed after surgeries are never used.

Ironically, I have heard that, with the up-scheduling of hydrocodone, some surgeons have increased the number of pills prescribed to prevent the need of a return office visit for a refill. Surgeons do not want callbacks when a patient needs opioids during recovery.

Prior to rescheduling, if a patient needed more hydrocodone, the patient could just call the doctor and request a refill.  The staff would then call the pharmacy to refill the prescription, and a family member or patient could then pick up the prescription even if it was after office hours. This cannot happen now, and that’s led to some fallout.

One of the consequences of the up-scheduling is that some doctors will now write a script in a large enough quantity to minimize the likelihood of callbacks, or to force a patient recovering from an injury to return to the office. That patient may not be able to easily get to the office since driving, or traveling independently, may be impossible during the recovery period. Getting help can be inconvenient or prohibitively difficult, and doctors understand that. Doctors who over-prescribe opioids for that reason are making it easier for the patient, and that can be the right thing to do. But, it’s still leading to over-prescribing medicine, and that can have unintended consequences of making more unused opioids available for diversion and use by abusers.

On the other hand, many patients who have been on opioids for chronic pain are being rapidly tapered to lower levels. The goal, in many cases, is to entirely discontinue the patients’ medication. This is happening because of the national attention that’s being paid to the opioid crisis. Physicians, health plans, and administrators don’t want to contribute to the opioid problem, so they are reducing or eliminating opioid prescribing.

People With Chronic Pain Suffer Because of Government Regulations

This under-prescribing of medication leaves many patients without opioids who have found them helpful and, for many, there are no other options. Their pain either is under-treated or not treated at all.

Reasonably, physicians are afraid of regulatory sanctions, DEA investigations, or even incarceration if one of their patients has an adverse outcome while using opioids.  Many physicians are more afraid for themselves, because of the consequences of prescribing opioids, than they are for their patients with pain who cannot get pain treatment.

To be as cautious as possible, many physicians and medical clinics are interpreting the CDC guidelines as policy — that is, they’re treating the guidelines as the law rather than as suggestions. That is the safest way for physicians and medical clinics to proceed, but it is not the best thing for many of their patients with pain.

The Opioids Paradox

So opioids are both over-prescribed and under-prescribed depending on which population you are referring to. The patients who don’t need as much medication as they’re being prescribed are still receiving excessive medication, and the patients who might benefit from opioids are increasingly being denied opioids.

That is the opioids paradox we now face, and our own grandparents would have told us just how wrong it is.


Purchase my book The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us (available on Amazon) or read a free excerpt here.

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Copyright 2016, Lynn Webster, MD


  1. […] The Painful Truth […]

  2. Dr. Greg Maloney, Ph.D. on April 15, 2016 at 2:40 pm

    There is too much “Gestapophobia” among practitioner who prescribe an opioid for valid medical conditions. Granted, the new “guidelines” published by the present administration by its agent – the CDC- are reminiscent of the “medical ” practices of the Third Reich in bringing control of all the country under the a “Fuhrer”; and classifying groups of people as unworthy of living-much less receiving medical care.

    The administration’s “anschluss” (German for -“takeover”) of how medicine is practiced in America-the former land of the free and home of the brave- will have severe consequences on patients in pain. They will be driven to the street corner drug-thugs dealers, rob a pharmacy; or receive the final treatment at a “euthanasia clinic”-whether they ask for it or not. Perhaps, the thugs who run both of these types of drug distribution programs, pay more to political coffers. If such conditions are unintended consequences, or a planned program, is a serious question, given the reckless disregard that the current administration has shown for the Constitution.

    Medical professionals, if they are worthy of the name, must stand against such abuse.

  3. Rebecca Wright on April 19, 2016 at 4:17 am

    I am very grateful to have come across your site this morning. Another sleepless night. I stopped counting a long time ago.

    I fell in 1993 and herniated L-4 through S-1 and recieved a chip fracture to my right hip. I was 31 years old and a workaholic, and as such I continued to work for another forty-five minutes after I fell. I lost feeling in my right leg and could no longer walk hence a trip to the ER was no longer optional. A thorough exam and several x-rays later, I limped out of there with an official diagnosis and some hydracodone for pain. They did little for the pain but I did take them as prescribed. I knew I was tough and could handle the pain. After all, in 1983 I had a hysterectomy and refused ALL narcotics. I was cut from one hip bone clear to the other. The doctors and nurses said I couldn’t do. I was terrified of addiction and brutally hard-headed. I managed to shock them all.

    Due to a botched epidural and a slip of the knife during back surgery, I am no longer that tough woman. Within a few weeks of the injury I was given the first of many epidural injections. It took 12 days for the hole to close during which time I couldn’t lift my head off the pillow without passing out. He never mentioned doing a blood patch and I knew nothing about them at the time. All I wanted was a Chiropractor and no drugs. My worker’s comp adjuster denied me that option. She didn’t believe in them.

    My Arach symptoms didn’t take long to manifest. Two years of epidurals and facet injections left me far worse off than I could have imagined. I finally opted for a small settlement and set up an appointment with my chiropractor. Six weeks later I was back at work. That was in 1995.

    The pain became progressively worse with each passing year. By 2004 I could no longer sit at a desk for eight hours without excruciating pain. My new Ortho did one epidural for old times sake and immediately off to the surgeon in his group who explained my odds. There was a 60-80% chance he would make me all better amd a 20-40% chance I would remain the same. No chance at all if becoming worse. How stupid we patients can be.

    The first ninety days were bliss. I used 49% of the allotted narcotics provided for my post-op recovery and went home eager to have my life back. No such luck. The pain came roaring back into the entire lower half of my body and I prayed for death. A CT confirmed my life sentence. Adhesive Arachnoiditis. He played it down as if it were nothing yet sent me home with scrips for Fentanyl, Percocet and Neurontin. No physical therapy. Just drugs.

    A prominent surgeon in Atlanta told me it was quite possible/probable that the other surgeon punctured the dura during surgery causing the Arach to rear its ugly head.

    I didn’t ask for this. I would gladly return it if at all possible. I often must choose between filling all of my pain med prescriptions or putting food on the table. There is no choice. My 71 year old mother, my 13 year old nephew and my wonderful husband will always have food before I even think about spending all that money for meds. This happens an average of 6 times per year.

    Almost 9 years of constant pain and silent accusations in each new doctor’s eyes brought me to the greatest doctor in the world. He is a physiatrist. Even though 50+ procedures have proven ineffective and 1 caused far more nerve damage than before, I allow him to try anyway because he is the very first one to ASK MY PERMISSION to perform procedures rather than tell me that was the only way I could get the meds which help me care for my mother and nephew.

    Tragically, he spent too much time with his patients and couldn’t keep up the rent so he was forced to join a group of Physicians. They have many locations in several states. Every month for the last six months a different doctor or PA has entered the exam room. I asked for him specifically every time. It took this many months for someone to just tell me the truth. I can’t see him because he is not “certified” with my insurance company. I have lost the only doctor I trust and in the meantime, the other doctors are trying to take me off all narcotics. I have been on Morphine Sulfate, 30 mg, tid for nine years. Same dose for nine years. I don’t go in once or twice a year begging to go up. I initiated the conversation with Dr. Amazing regarding lowering the amount of breakthrough meds. I have gone from four Roxicodone a day down to two 10 mg Percocet which doesn’t even begin to do the trick but what the heck? I will live. Right? I’m not sure at this point. The plan is to stop all narcotics at my next appointment. Not my plan, theirs.

    While I would never want to hurt my family and I have no plans to end my life, I can honestly say that that option is now at the forefront for the first time in 23 years. I can go a week to 10 days without meds so the family can eat. Forever? I think not. All I do is cry all day and night. It hurts too much to sit up. I will be of no use to my family. I will be nothing more than a burden. I won’t put them through years of that garbage.

    I am sorry for writing a book on your page. I am just so damn tired and I feel as if no one is listening to us or even caring about those of us for which there is no cure and no hope. Thirty hours from now I will loose the only thing that allows me to partially function.

    All I have left to say us thank you to the addicts and to the people who continue to supply them their drugs. News flash. The war on drugs is over. We lost.

    I will understand if you don’t approve my post. I just needed to be heard.

    Thank you,

    Rebecca Wright

    • Susan on April 25, 2016 at 10:32 am

      I completely understand. I am having the same problems. Just had spinal fusion in my neck and when I am sufficiently recovred, I will have surgery on my lower back. I too am nearing the limit of what I can endure. I am so sorry that you are suffering so.

    • jody pangerl on April 28, 2016 at 9:52 pm

      I am sorry to read your post. I am in the same boat. Chronically ill and severe chronic pain. My drs are taking me off my pain meds. The only relief,I have ever had. The dr. I trusted has left. I do not want to live like this.

  4. MARISSA on April 26, 2016 at 10:11 am

    Rebecca, you are not alone. I’m very sorry to hear of all the struggles you have endured and the sacrifices you’ve made for your family. I’ve had similar experiences and completely understand what you mean. I hope and pay that you can find a pain management doctor that will understand you’re needs and have the strength to prescribe what helps you. Thank you for sharing you’re story. You are a true inspiration and I’m amazed at your strength and patience. I wish you the best of luck.
    Dr. Webster, your articles are so intriguing and resonate with my experience over the last decade. The restrictions have just made life more difficult as a chronic pain sufferer. I hope and pray there will be more doctors with your intelligence and strength to acknowledge the flaws in the system. Thank you for sharing your insight into a very complex issue. Your input has been much appreciated and gives me some hope for the future.

  5. Christie Annos on May 3, 2016 at 4:13 pm

    15 years of chronic kidney pain from multiple boutss of kidney stones. 12 years on the same dose of morphine. No negative side effects or dose increases. Followed ALL the rules. Allowed me a basic but acceptable life. 4 years ago Kaiser Permanente said my dose was too high. Long story short, reduced my meds over the course of the last 4 years, until they took them away atogether. Didn’t offer me alternatives, except “pain classes”, pain psychologist. Said I could try acupuncture, but they wouldn’t pay for it. Now my pain is so bad I think about dying every day. They don’t care, they offer me nothing. Somehow they seem to believe this is “for my own good”. Getting new insurance June 1st. Still a little hopeful, but so scared I’m going to find the same thing.

  6. Jeannette M. Poulson on August 23, 2016 at 2:24 am

    Dear Dr. Webster,

    I wanted to briefly share my story and how I’m affected by the CDC opiate guidelines.

    There’s plenty to say right now about the CDC’s 12 opiate recommendations. We can scream our stance on the issue all we want when in the long run; We overlook the unintended consequences that are happening.

    As a physician I’m sure you agree with it’s about striking a balance in a patients care easing suffering while minimizing harm. We are getting so preoccupied with addiction prevention, we don’t see what’s happening to chronic pain patients that rely on pain medication to improve quality of life. Improved life function is benefit from medication. If properly monitoring the patient to ensure medication is taken as prescribed without adverse health risk, benefit outweighs risk, but this is where appropriate screening and education should be implemented instead of reduced access on a national scale that allow people with a severely compromised life to fall into a lurch.

    The problem of stating that “non-opioid therapy is superior to opioid therapy for all chronic non-cancer pain” is that you leave out the ability to have treatment appropriateness per diagnosis or severity of pain, then there’s the admission that there aren’t comparative equal studies to reinforce that statement. I’d think it more appropriate to mention that mild and minimally restrictive pain towards should be steered toward opiate free therapy. There are rare and debilitating illnesses just as excruciating as cancer. I’m living with more than one, LPHS, Interstitial cystitis, severe degenerative spinal changes with extensive herniated disks, and bone spurs, and pancreatitis to boot! I with many others are now being abandoned by their doctors, and allowed to suffer. Quality of life is no longer a part of the conversation, and evidence now shows, also being reflected by the CDC that unexplained suicide is on the rise.

    Many stories are coming out that patients are ending their lives because of undue suffering and neglect by their doctors. We are human! We aren’t designed for immense suffering. Life has to be balanced between what we can physically handle and what we can’t. Benefit certainly outweighs risk when life is managed and opiate related harm isn’t deemed a risk. From a law perspective, language this broad such as the guidelines put forth by the CDC that has no mention of specifics, i.e.: diagnosis, severity of pain or treatment appropriateness is considered criminal and indicative of neglect, and thus the reason many are suffering needlessly. It’s not a question about harm of opiates, but rather individualized care models. It depends on the diagnosis! yes, opiates shouldn’t be first line treatment, but there are no studies to prove opiates ineffective on pain. It should always be the judgement and discernment of the doctor to know what’s best for the patient.

    Evidence is showing that doctors out of fear are abruptly stopping or reducing medications when not necessary, compounding suicide rate, which is now surpassing the overdose rate. The goal is to minimize risk instead of making medications now almost nil, and that requires education, and proper screening as well as expanding insurance coverage to include complimentary therapies, which many don’t have, making the opiate problem more complex and inflicting more harm as people are now looking to suicide to end their suffering.

    If we are to halt addiction, then we must take care to not penalize those not part of the opiate crisis. These are two different problems. We are causing indirect destruction resulting in exponentially rising unnecessary deaths.

    Unless ones knows personally the impact of chronic pain, they don’t know the detrimental effects on the quality of your life. I discreetly know an MD who’s also a pain management patient. I collaborate with physicians and addiction specialists alike. They tell me their stories of frustration and regulatory intimidation every day.

    Another disparity to the overdose deaths is that many suicides are misclassified admittedly by the CDC. Since 2014, the difference between illicit and prescription fentanyl couldn’t be discerned in the system, even Tom Frieden, director of the CDC said because of this, the numbers projected aren’t reliable, also saying that some heroin deaths are misclassified as prescription morphine due to it’s similar metabolism. Once controlled substances are found at the time of death, it’s often presumed an overdose and accidental. Complicating this is the state regulations in how certificates are carried out. Under treated pain may be the cause of death as well causing someone to end their life, and sudden death caused by uncontrolled vitals are also a possibility and does happen. Due to my uncontrolled pain and complications of pancreatitis, they’re through the roof!

    I’ve been with my clinic for 16 years and have been monitored regularly to rule out abuse of my medications, but my cries for help are going unheeded, and no one is willing to even have this conversation with me about my pain needs. I’m in pain daily, and barely able to eat due to pancreatic attacks several times a day. I’m having fluid build up and my heart rate soars to over 140 bpm, and still I’m being ignored. What is happening now to chronic pain patients who aren’t deemed an opiate risk is nothing short of humanity at it’s worst. I don’t believe we’ve ever seen it to this degree since the Holocaust! How is it that our presidential administration is allowing this kind of neglect to take place? What is a recourse for patients like myself?

    Also problematic is that there’s delaying of pain relief for those with undiagnosed painful conditions such as cancer and pancreatitis, truly causing needless torment and suffering.

    I admire the work that doctors like you, Dr. Fields, and Dr. Fudin are doing to advocate for those that are already vulnerable and have to live with the burden and challenges that chronic pain brings without having to bear the extra weight of shame, stigma, and guilt. How do we fix this?

    Please continue to be a voice for those of us who now are victimized and suffering greatly from the fallout of the CDC Recommendations and who have no choice but to endure our severe chronic pain without or dose ineffective medications as well as being forced to take medications that don’t work.

    We must strive to empathize and put an emphasis back on “First do no harm.”

    I welcome your feedback.

    Jeannette Poulson

  7. Kenneth Brown on January 23, 2018 at 4:40 pm

    I have been on opioids since 1990. Not only is my doctor limited in what he can prescribe to a chronic pain patient but the insurance companies are telling the doctors what the can prescribe. I I really think that this problem is all about insurance. Pain medication isn’t cheap and the insurance companies are laughing all the way to the bank. I know that I will have to end my life without my medicine for pain. It’s so sad as I love my dear wife and don’t want to hurt her by me having to check out of this world. Someone needs to stand up and tell the truth. Thank you and God Bless all of you.

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