Published by New England Journal of Medicine

Mr. P. is a 34-year-old man who sees his primary care physician regularly for chronic spine pain. Several years ago, he had a motorcycle accident that left him with a ruptured spleen, a shattered pelvis, and multiple thoracic vertebral fractures. After a prolonged hospital and rehab course, he was discharged without neurologic sequelae but with a severe chronic pain syndrome. The accident was a wake-up call for Mr. P. He stopped using alcohol and drugs, got a job, and began paying child support. His daily pain regimen consisted of 3600 mg of gabapentin, 60 mg of baclofen, 120 mg of oxycodone IR (a 180-mg morphine-equivalent dose), and nonsteroidal antiinflammatory drugs as needed.

Mr. P.’s condition had been stable on this regimen for 2 years. His prescription-drug monitoring reports and urine toxicology screens were pristine. Unfortunately, his primary care physician announced that her practice had adopted a no-opioid policy. Mr. P. was given a prescription for a month’s worth of oxycodone and advised to find another prescriber in the future. Not unexpectedly, six other physicians refused to prescribe him opioids, and he ended up in our pain clinic, sobbing in the exam room, terrified that he’d end up “back in my old life” if he had to buy his pain medications on the street.