A Close Look at Denial of Pain Meds to People Who Use Drugs

April 18, 2024

For people who use drugs, accessing prescription pain medication when needed can be a severe challenge. A new paper digs into this issue by investigating factors that may cause a doctor to prescribe or not prescribe to people who use drugs (PWUD)—and what people do if they’re turned away.

“I think the way the health care system is developed is not necessarily with a harm reduction approach,” Evelyne Piret, one of the paper’s authors, told Filter.

The paper was published on March 28 in the Harm Reduction Journal. It studies outcomes for 1,168 Vancouver-based participants who had asked to be prescribed pain medication—of any kind, such as opioids, gabapentin, muscle relaxants, over-the-counter medicine like tylenol, cannabinoids or unspecified drugs—between 2012 and 2022. The pain that people hoped to treat was related to situations including surgery, injuries and various types of chronic pain, among others.

This data came from three ongoing studies with PWUD in the city: The Vancouver Injection Drug Users Study, the AIDS Care Cohort to Evaluate Exposure to Survival Services, and the At-Risk Youth Study. All participants in these projects were using banned drugs at the time they joined.

People’s self-management of pain prior to seeking formal treatment for pain was a factor associated with denial.

Conducting a statistical analysis of health care visits across 4,179 six-month observation periods, the team found 907 reports (21.7 percent) of a person being denied a prescription for pain medication.

Their analysis showed that factors positively associated with denial included: having experienced a non-fatal overdose; accessing opioid agonist therapy; and daily use of opioids from unregulated markets. Being younger was also positively associated.

In something of a Catch-22, people’s self-management of pain prior to seeking formal treatment for pain was another of the factors associated with denial.

Participants who reported self-managing pain variously did so with unregulated drugs; with prescription drugs which hadn’t been prescribed to them; with cannabis or other regulated drugs; with over-the-counter medicines; or, less frequently, with exercise or heat therapy.

This all illustrates some of the likely elements—whether decisions are based on prejudice, or on medical professionals’ perceptions of risks—behind denial of pain medications to PWUD, according to Piret, who is a graduate student at the University of British Columbia’s School of Population and Public Health, and works at the British Columbia Centre on Substance Use.

Being denied pain medication can leave people to suffer mental and emotional pain, as well as physical pain, she pointed out.

These outcomes could also worsen an already-difficult relationship between PWUD and the health care system by adding to stigmatization of drug use and potentially fostering adversarial interactions. This, in turn, could hinder opportunities for health care professionals to provide care for PWUD beyond pain management, Piret said.

The study also examined what PWUD did after being denied pain medications. Among the 895 reported actions taken post-denial, 53.5 percent saw a person turn to unregulated drug markets instead, and 6.1 percent involved a person going to a different doctor.

Piret noted that the paper cannot be taken as proof that being denied pain medications directly causes people to self-medicate with non-prescribed drugs. The connection has been widely drawn elsewhere, however.

“We’ve known this for a long time.”

The paper’s overall findings come as no surprise to John Braithwaite, a board member and supervisor for the Vancouver Area Network of Drug Users. “We’ve known this for a long time,” he told Filter. He’s experienced being denied pain medication himself, he said, and many people constantly go through this.

Braithwaite also described how the body language and attitude of a medical professional can suddenly shift, once they become aware that a patient is on a methadone program, for instance.

“Everything kind of changes. They’re reluctant to give you any kind of real painkiller,” he said. “Well, it’s frustrating … just to see someone change so drastically just because you’re on a doctor-prescribed medicine.”

Braithwaite said that this has become more common since 2016, when the College of Physicians and Surgeons of British Columbia (CPSBC) released a legally enforceable set of guidelines to reduce prescribing of opioids and certain other drugs.

“The College expects physicians to use their own professional [judgment] to make treatment decisions in the best interest of their patient,” the CPSBC emailed in response to Filter’s request for comment. “The College practice standard Safe Prescribing of Opioids and Sedatives does not prohibit prescribing; it provides principles to make prescribing opioids and sedatives, which carry risk, safer.”

“I would really love to see guidelines specific to the management of pain among people who use drugs.”

Piret said that the new research didn’t seek to evaluate these prescribing guidelines—and the study notes that the guidelines did not seem to change denial rates. But she added that they do provide important context to what’s happening.

The paper stated that these guidelines, and others released in 2017 by the Canadian government, “may be mismatched with the realities of PWUD.”

“I would really love to see guidelines specific to the management of pain among people who use drugs,” Piret said. These, she envisages, would cover “all of the special considerations around drug use and drug interactions and access to care.”



Photograph by Karolina Grabowska

Doug Johnson

Doug is a writer, editor and journalist whose work has appeared in National Geographic, Undark Magazine, New Scientist and Hakai, among others. He lives in Alberta, Canada.

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