Don’t lecture physicians on ‘cautious prescribing’ of opioids

April 9, 2018

Physicians answer to patients, not pharma, when it comes to the prescription of powerful opioids.

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With the opioid crisis touching almost every life in this country, there are new guidelines for prescribing medications for chronic pain. Every day there is another tragic story concerning this epidemic in the local newspaper. Thousands are dying of overdoses and patients and families incur extensive suffering. It is estimated that 115 lives are lost per day to opioid overdose in the United States.

Recently, in my local paper, there was an article about an opioid drug manufacturer who agreed to stop promoting opioids to doctors. The company eliminated half of its sales force and was no longer going to send representatives to doctors’ offices to promote the drug. A director of an opioid policy research group at a well-known university thought this was helpful. However, he said it would not make a big difference unless other opioid drug companies did the same.

He said it was “difficult to promote more cautious prescribing to the medical community because opioid manufacturers promote opioid use.”

You may want to read that last sentence again. It is preposterous. The medical community as well as the lay community are all too aware of the need for more cautious prescribing. I don’t know of any physicians who are writing opioid prescriptions willy-nilly nor inappropriately because of drug company sales representatives pitches at this point in time. This is an epidemic burning across our country wreaking havoc with young and old alike. Doctors don’t need someone to tell them not to prescribe opioids. We are very aware of the issue.

It hits us head on every day in the office with patients who have lost children, spouses who are in bankruptcy and afraid to go home, and children who don’t understand what is wrong with mom or dad. Please don’t think that a sales representative can talk us into contributing to this crisis. Physicians as a group tend to be caring, and want the best for our patients. The best for everyone regarding opioids is very close monitoring of prescriptions and limited amounts dispensed.

Next: 12 key points for prescribing narcotics

 

That said, the Center for Disease Control and Prevention (CDC) published new guidelines for prescribing narcotics with 12 key points. I have abbreviated them here for a quick review.

  • Nonpharmacologic therapy and nonopioid pharmacologic therapy are recommended as first line treatment for chronic pain which is pain present for longer than three months.

  • Before moving to opioids, clear treatment goals should be established with the patient including when to stop the opioids if there is no improvement.

  • The risks and benefits of opioid use should be discussed with patients.

  • When starting therapy, use immediate-release preparations first, not long-, and start with the lowest effective dose.

  • If treating acute pain, rarely is more than seven days of therapy needed.

  • With chronic pain, reevaluate the situation within four weeks of start of therapy or increase in dose.

  • Always assess risk vs. benefit every three months in chronic opioid use.

  • Providers should have a strategy to decrease risk from opioid use in all patients including considering naloxone if risk of overdose is present.

  • Clinicians should also check the state prescription drug monitoring program before prescribing opioids.

  • Also, urine drug testing before start of therapy and at least annually is recommended to look for the prescribed meds in the urine and to screen for other controlled and recreational drugs.

  • Try not to prescribe opioids with benzodiazepines if at all possible.

  • Offer evidence-based treatment for patients who are abusing opioids. (i.e. methadone, suboxone)

Of course, these are important guidelines to follow, but I have to think that most providers find these guidelines to be common sense. Knowing what is happening in our communities with the devastation of families and the loss of young lives is changing the way all prescribers treat opioids.

The crisis is front and center in our practices and hopefully all providers are doing their best to help by cautious prescribing.