Opioid Stewardship

We are an interventional pain practice, not an opioid practice. The distinction matters, so here it is in plain terms.

What we will not do

We will not take over a high-dose opioid prescription and simply keep signing it. We will not increase a dose because the last increase stopped working. We will not treat escalating tolerance as if it were escalating disease.

If that is what you are looking for, we would rather tell you now than after you have taken time off work for an appointment.

What we do instead

We find out what is generating the pain and treat that directly. For most patients that means image-guided injections, nerve blocks, radiofrequency ablation, physical therapy, and attention to the things that keep a nervous system sensitized — sleep, blood sugar, inflammation and deconditioning.

As the pain source comes under control, the opioid dose comes down. That order matters. Tapering someone whose pain has not been addressed is not stewardship; it is abandonment with better paperwork.

If you are already on opioids

Most patients who come to us are, and nobody is turned away for it. Coming to a pain clinic on an opioid prescription is the normal starting point, not a mark against you.

• You will not be discharged at the first visit for being on an opioid.
• You will not be tapered faster than you can tolerate.
• You will not be left mid-taper without a plan.
• You will be asked to use one prescriber and one pharmacy, and we will check the prescription monitoring program — for every patient, not as an accusation.

What tapering actually feels like

It is harder than the pamphlets suggest. Coming down off a long-standing dose usually takes months rather than weeks, and there are stretches where pain and sleep get worse before they get better. Patients deserve to hear that at the first visit rather than discovering it at the fourth.

What makes it work is that the taper runs alongside real treatment, not instead of it. When the underlying pain generator has been treated, each dose reduction costs less than the one before.

Why we take this seriously

Missouri has spent two decades absorbing the consequences of treating chronic pain primarily with opioids. The people who paid for it were patients who did what they were told. We are not interested in repeating it, and we are equally uninterested in the overcorrection — leaving people in pain to keep a prescribing average tidy.