With the increasing number of opioid-related deaths over the past few years, many doctors and other healthcare providers have come under tremendous scrutiny by medical boards, the Drug Enforcement Administration (DEA), and the court system. Recent tragic deaths of celebrities, most recently Prince, have brought this ever growing epidemic into the spotlight. Several factors are associated with this trend in medicine.
Consider a patient who suffers from chronic pain who has exhausted all conservative and non-conservative treatments, including invasive surgical intervention. There may be limited treatment available for that patient besides prescribing opiate medication. Certainly, each patient is different and each doctor may have different comfort levels prescribing different doses of opiate medication. There should be, however, a very systematic approach to initiating such treatment.
Checks and balances
It is the prescribing provider’s responsibility to make sure checks and balances are in place before prescribing opiates. This begins even before the initial encounter. Virtually every state has a form of prescription data monitoring to track opiate prescriptions. This has proved a great way to both monitor compliance with what has been prescribed as well as to discover a patient that may be doctor shopping. There is an important limitation to this, however—not all states share the data. A patient can easily go to a neighboring state and present with legitimate pain along with supporting diagnostic testing and receive yet another prescription. The governing body, the DEA, should develop a central database that accounts for any prescription written for controlled substances. New York State has mandated that all prescriptions be sent electronically. If other states follow suit, it will make a central database easier to compile.
An appropriate risk assessment screening process needs to be in place to determine whether a patient is at higher risk for potential abuse and diversion of medication. This is partially achieved with in-office toxicology testing to screen for illicit drug use.
Marijuana, which has become ever so popular, remains a DEA Schedule I drug classification. To date, there is limited medical literature that supports the use of cannabis for pain relief. While current research is promising and may provide an alternative treatment for patients suffering from pain, the effects of combining different types of medications and drugs, including street drugs, are not well documented. Let’s take a conservative approach and equate marijuana to alcohol. You wouldn’t recommend that your patient drink and take opiate medications, right? So, why would it be ok to mix opiates with marijuana? There is no consensus on prescribing opiates to patients who use marijuana. I recommend a great deal of caution as street-obtained marijuana may be laced with other substances, including fentanyl. Furthermore, use of recreational marijuana should raise awareness as to why a patient may be seeking an opiate medication.
Patients deemed to be at higher risk for abuse need to be monitored and have more frequent office visits to ensure compliance with their treatment. They also require more frequent toxicology testing. This is time and staff intensive. But in this era of resource constraints, how much time and manpower are really practical to make certain these measures are implemented? I believe the system as a whole needs to be revamped if we are going to be able to provide the care many of these patients require.
Frequently encountered in a clinical setting is the rampant street access to opiate medication. This availability may be a result of poor compliance or good old drug trafficking. Whatever the case may be, many patients are able to obtain pharmaceuticals on the black market. On multiple occasions after discussing with patients why they are not appropriate candidates for this class of medication, they respond in a very calm and confident manner saying,
“That’s OK doc, I’ll just get it on the street.”
Undeniably, over-prescription is an issue that faces the medical community. This is not a result of medical negligence, but a desire by the physician to provide comfort and quality of life for his patient.
The risk of addiction
Opiate medications are, by their nature, addictive. This must be discussed with every patient prior to initiating treatment. It behooves a physician prescribing opiates to set a threshold dose that will not be exceeded. Should a patient be non-compliant with the treatment, or display signs of developing addiction and dependence, a physician should, without fear of labeling the patients as an addict, make an appropriate consultation to an addiction medicine specialist sooner than later. This does not abandon the patient but provides a way to treat a developing concern.
Further, I believe that primary care providers should not be so quick on the trigger to prescribe opiates as first-line treatments for pain relief. They should manage the patient conservatively with non-controlled medication and physical therapy and refer to the appropriate specialty before prescribing opiates.
There is nothing preventing a patient from walking into the neighborhood drugstore to purchase readily available bottles of acetaminophen, diphenhydramine, etc. and taking more tablets beyond the recommended dosage listed on the bottle. The same holds true for a patient with a bottle of prescription medication. There is patient responsibility to adhere to the instructions as provided by the physician and pharmacy. Having so called “skittles parties” with a bag of controlled substances has the potential for serious including fatal consequences. Too often, physicians encounter the following,
“I ‘borrowed’ a pill from my friend/family member; I lost my pills; one pill wasn’t enough so I took two.”
It is ironic how blood pressure medications never seem to “fall down the sink drain,” whereas opioids often do. These are red flags and should serve as warning signs to potential abuse.
No patient woke up one day and decided they want to be in chronic pain. There are many with legitimate conditions that warrant the safe use of opiate medication which plays an important role in managing pain. I think we’re all looking to achieve the same end result which is to provide pain relief for the patient in the most efficient and safe manner possible. As these overdose incidents become more prevalent, creating media uproar, the swift reactions through legislature may cause the pendulum to swing to the other extreme and limit access to medications. This is frustrating to patients and physicians.
There isn’t a simple solution. Each patient is an individual and has to be treated with a tailored regimen. Each doctor practices a certain style and may be comfortable with higher doses of opiate medications. But yet, they are both met with aforementioned challenges. Together, through the collaborative efforts of doctors by establishing and adhering to guidelines, pharmacies to properly report to state prescription monitoring agencies, the DEA through better control and regulation of illegal sources of medications entering the market, and, very importantly, patients taking responsibility, in a combined effort to combat this opiate-related death epidemic, we can prevail in this contemporary war on drugs.