How physicians can help patients, community
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.
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.
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.
Patient pain management contracts are another tool doctors often use both to help patients and ensure they aren’t selling or giving away opioid medications. Such agreements generally require the patient to come in regularly for urine tests and pill counts.
Robert Raspa, MD, a primary care physician in Jacksonville, Florida, says his practice instituted them about a decade ago after a nearby medical center stopped accepting patients with Medicaid coverage.
“All of a sudden new patients started showing up saying they needed their medications renewed,” he recalls. “We knew it was a dangerous situation we weren’t prepared to handle, and one way we responded was to institute these contracts.”
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Marla Kushner, DO, a primary care physician in Chicago, focuses solely on helping patients with opioid dependencies or addictions, and usually with the aid of medication-assisted therapies such as Suboxone (bupenophrone). Her contracts include the requirement that patients attend 12-step programs, such as Alcoholics or Narcotics Anonymous, as part of their treatment. It’s part of her larger conviction, which she emphasizes to patients, that success in managing addiction, or overcoming dependency, ultimately is up to them.
“I always tell them, ‘you don’t have a choice to have this disease, but once you know you do, you can decide what you’re going to do about it. Are you going to take your medication, are you going to work a program?’ That’s where the choice comes in,” she says.
Like many physicians, Kushner has had to drop patients who break the terms of their contracts, such as requesting refills by telephone rather than coming to the office. But she doesn’t drop patients if they relapse, due to her belief that addiction is a chronic disease, and needs to be managed like other chronic diseases such as diabetes.
“A diabetic eats a piece of chocolate cake. That doesn’t mean we’re going to kick them out of the practice,” she points out. “We work with them to figure out what we could have done differently to keep their blood sugar under control.”
The same approach should apply to people with opioid addictions, she says. “I want patients to feel if they relapse this is a safe place for them to talk about it so we can come up with a different plan,” she explains.
Educating patients, both about the effects of opioids and the importance of not allowing other people to have access to them is also important. That’s especially important for families with children, says Sandra Adamson Fryhofer, MD, an Atlanta, Georgia internist. “I’ve had some patients whose kids have gotten hooked on drugs from something they found in the family’s medicine cabinet,” she says.
Because of that, she tries to make clear to all her patients the importance of keeping medications out of the reach of children and teens. “I want them to be aware that other people may have access to what’s in their medicine cabinet,” she says.
Kushner stresses the importance of informing the public about the true nature of addiction but with a different emphasis. “I think it would be helpful to educate people more that opioid addiction is a disease, not just a weakness and not something people choose to go through,” she says.
A further important element in battling opioid abuse, doctors say, is a thorough and detailed work-up of new patients seeking opioid prescriptions.
Sullivan, for example, says his patients generally fall into one of three categories-patients whose functions can be improved with pain medications, including opioids, opiate-dependent patients who can’t function without them and people seeking to divert (sell) their medications. For patients in the first two categories, he assesses their level of opioid tolerance and how the medications affect other parts of their lives.
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“Any time I see patients taking opioids, but they are fully functional in their job and able to take care of themselves, then I feel comfortable prescribing these medications,” he explains. “If I see decreased ability to function, that’s a dangerous sign and I change them to less-sedating medications as soon as possible.”
Kushner emphasizes family histories in her patient workups, looking for evidence of alcoholism or other forms of substance abuse. “That may show a genetic link [to dependency],” she explains. “And if it looks like my patient does have the potential for addiction, I’m going to be a little more conservative with them and do closer follow-ups.”
Despite their best intentions, however, doctors admit they are often hamstrung in their efforts to battle the spread of opioid abuse by the same factors that hinder other initiatives to improve patient health: lack of time and money.
The entire healthcare system, they say, is geared toward getting patients in and out as quickly as possible-exactly the opposite of what a patient struggling with addiction requires.
“A doc can say, ‘I’ll spend time talking to my patient explaining the danger of these drugs and trying to get them to go to physical therapy instead, or I can write a prescription and have them out in five minutes,’” Raspa says. “It sounds callous, but in a busy practice where you want to get back to treating patients with diabetes and heart failure, it’s a quick way to get them out of your office. Doctors are being pressured from many sides, and sometimes they don’t do the right thing.”
Raspa adds that he’d address the problem by eliminating the pain scale, and anything having to do with narcotics from patient satisfaction surveys. He’d also increase the number of rehabilitation centers. “It would be nice to get people off these meds in a safe, controlled environment,” he says.
Osborne notes that many of her patients who use opioids have “complicated psycho-social histories. Many times they’re in messy marriages and living nightmare lives,” in addition to battling problems such as obesity and smoking. Thus weaning them from the medications requires addressing the other issues in their lives, a process that requires a great deal of time and patience.
“I spend at least an hour with each patient, do house calls, attend school conferences, educate other providers,” she says. “That helps patients to be well and safe, and causes me to be poor, because the [healthcare] system doesn’t recognize that type of work. That’s what gets so frustrating.”