After years of simmering in the background, opioid abuse has exploded into the worst public health calamity the nation has faced in decades. Tens of thousands of people die from overdoses each year, with many more becoming addicted or physically dependent on the medications. The crisis has seeped into virtually every part of the country and touched individuals and families from all types of backgrounds.
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The severity of the problem, combined with news stories about high-profile deaths, such as the son of the mayor of Nashville, Tennessee, sometimes creates the impression of opioid abuse as an unstoppable—and incurable—epidemic. But doctors who treat patients with opioid dependencies or addictions paint a different picture. Addiction is a chronic disease, they say, and like other chronic diseases it can be managed. But doing so requires time and money, along with a changed attitude among many lawmakers and members of the public.
In August, President Donald Trump formally accepted what public health experts, law enforcement and physicians have been saying for years: opioid abuse is a deadly epidemic, and should be declared a national emergency.
As with any major public health problem, the spread of opioid addiction has many causes, including a belated recognition of just how potent the drugs can be. “I think a lot of us, me included, underestimated the power opioids have over certain people,” says Greg Sullivan, MD, who has been conducting clinical trials of drugs designed to help people overcome opioid addictions for more than two decades while practicing as an internist in Birmingham, Alabama.
Especially at risk, he notes, are individuals “with ongoing stress in their lives or psychological issues that they feel are improved by taking these medications.”
In their earlier willingness to prescribe opioids, Sullivan adds, many physicians—himself included—were responding in part to The Joint Commission’s 2001 standards on pain assessment and treatment. Many thought the Commission had endorsed the use of pain as a patient vital sign—a perception that the commission has since refuted.
Moreover, he notes, some payers had begun including patient pain management in their physician evaluations, and studies had appeared in leading medical journals claiming that patients with chronic pain were not getting addicted to opioid medications. “It was a perfect storm that led to the overprescribing of opioids” for pain management, Sullivan says.
What doctors can do
So what can doctors do in their own practices to curb the availability of opioids, and to help those who have developed an addiction to the medications? And what systemic changes do they think could help achieve these goals?
Experts say a good place to start is by following the recommendations in the Centers for Disease Control and Prevention’s 2016 guideline regarding the use of opioids for treating acute pain, such as that following surgery or a bad accident: prescribe the minimum number and potency needed to get the patient past the worst of the pain, then look for alternatives such as non-steroidal anti-inflammatory drugs and/or physical therapy.
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“Basically, the CDC is saying ‘when people come in with limited problems, don’t make them opiate addicts,’” Sullivan explains. The guideline was intended mainly for primary care physicians, who now write nearly half of all opioid prescriptions, and among whom prescribing rates have been increasing faster than other specialties, according to CDC data.
Preventing doctor shopping
Helping patients who have used opioids for extended periods—due either to chronic pain or addiction, and weaning them off the medications—present far greater challenges, doctors say.
One of the biggest is guarding against doctor shopping—patients who seek opioid prescriptions from multiple providers. In recent years, states have acted to combat the practice by establishing Physician Drug Monitoring Programs—electronic databases for tracking the prescribing and dispensing of controlled prescription drugs. These programs enable doctors to learn what other prescriptions for controlled substances a patient has had filled in that state.
Careful screening of patients also helps to prevent doctor shopping. Susan Osborne, DO, a primary care provider in the rural town of Floyd, Virginia, has members of her staff question potential new patients as to why they want to see the doctor, and whether they’re calling on behalf of themselves or someone else.
“If it’s something like a mother calling on behalf of an adult child or wife calling for a husband, that can be a red flag,” Osborne notes. Another sign of possible doctor shopping, she says, is a patient refusing to release his/her records from previous physicians.