CSA Online First

CSA Online First is a weekly blog featuring insights from CSA members themselves.

Edited by Rita Agarwal, MD, FAAP, with contributions from CSA’s Committee on Professional and Public Communications, Online First is a place where knowledge and opinion from any one of our 3200 plus physician-anesthesiologist members can be shared, discussed and deliberated to advance the specialty of anesthesiology, the practice of medicine and society in general.

"Better solutions to difficult problems are usually made when all sides are heard."

Steven Goldfien, MD

 

Addiction is a Disease

by
  • Agarwal, Rita, MD, FAAP, FASA
| May 29, 2018

Limiting physician’s prescriptions to patients won’t solve the opioid crisis 

Physicians (and other health care providers) may have inadvertently contributed to the opioid crisis, but they are no longer actively contributing to it.

Addiction is a disease.

cdc graph 2

Overall prescriptions for pain medications have decreased since 2012. In 2017, the number of opioid prescriptions decreased to their lowest levels in over 10 years and back to levels prior to the start of the opioid epidemic. The number of deaths and near deaths from opioid overdose (intentional or not) have contributed to the increase.

Many journalists, lawmakers, and members of the public continue to blame physicians and big pharma for the opioid epidemic, forgetting that nurse practitioners, physician assistants, and dentists are among the biggest prescribers.

There is no question that the liberal use of opioids for treatment of chronic pain and after minor trauma or surgery contributed significantly to the problem. However, education, awareness, and attention on the problem have decreased prescriptions of opioids, presumably decreasing supply.

Unfortunately, that has not helped or slowed down the continuing crisis. As the graph cdc graphbelow shows the increase in overdose death in the past eight years is due to heroin and synthetic opioids. The number one culprit now is fentanyl. Knock off fentanyl manufactured in China and India, cut with who knows what additives, added to heroin and other street drugs. Further limiting prescription drugs is not going to have any impact on these deaths.

Lawmakers with few exceptions, are not physicians. By April 2018, 28 states have some sort of limits on opioid prescriptions most focusing on total number of days an opioid may be prescribed, others limiting the total dose in morphine milligram equivalents (MME). They range from a 14-day limit to a 3-day limit.

The California Assembly recently voted overwhelmingly to limit the opioid prescriptions for children to five days (AB 2741). I rotate on the inpatient pediatric pain service at Lucille Packard Children's Hospital Stanford approximately one week/month and write these prescriptions all the time. I base my opioid choices, doses, and medication amounts on the patient’s usage and needs in the hospital, the type surgery, the anticipated pain and recovery, the patient’s medical conditions, and a multitude of other factors, but clearly, our lawmakers know better. There is some science behind these seemingly random limits. The CDC has found that the incidence of long-term opioid use increases after a three or five-day supply of these medications, and again after 31 one days.

There are multiple other risk factors, but unfortunately dealing with those can be more complicated, costly, and difficult to implement.

Addiction is a disease, artificially limiting or restricting medications for legitimate medical reasons is not the solution. Non – physicians practicing medicine and creating barriers for patients to receive needed and appropriate treatment is not helpful. Focusing on the risk factors for addiction, and the misuse of opioids is a more important approach.

The CDC has studied the epidemic extensively and has a list of recommendations:

  • Report non-fatal and fatal opioid overdoses more quickly, identify hot spots, and rapidly respond with targeted resources;
  • Identify risk factors for fatal overdoses;
  • Increase comprehensive toxicology testing and support to medical examiners and coroners;
  • Share data with key stakeholders also working on prevention activities;
  • Share data to improve multi-state surveillance and response to the epidemic;
  • Enhance prescription drug monitoring programs;
  • Implement and evaluate strategies to improve safe opioid prescribing practices;
  • Share CDC’s Rx Awareness communication campaign to increase awareness and knowledge among consumers about the risks of prescription opioids.

Prescription Drug Monitoring Programs (PDMP) are of critical importance to these efforts. Allowing states to share information can really help prevent the ability of patients to “doctor shop” or obtain opioids from physicians in different states. California uses The Controlled Substance Utilization Review and Evaluation System (CURES). While not perfect, it is fairly easy to use and reliable. There are changes and mandates coming up in the next few months, that may impact many of us regarding the use of CURES prior to prescribing controlled substances. Making sure that CURES is always easy to use, and always reliable will be critical.

cdc graph 3

Some physicians have decided to stop prescribing opioids altogether, others are choosing grossly inadequate doses for fear of “reporting” to State Licensing Boards. Dentists and others are looking more critically at their prescribing habits. The prescription numbers have already decreased substantially, the incidence of death and morbidity related to opioid overdose is continuing to increase exponentially. More and more patients are turning to illegal and uncontrolled sources of opioids to relieve their pain (physical or psychic), and patients with who have been stable and functional on opioid regimens are suffering.

Clearly, further prescription reduction is not the answer.

cdc graph 4

Addiction is a disease. Improving and increasing mental health services, increasing access to care, funding research to develop better pain medication and treatments, mandating payment by insurance companies for the use of non-pharmacologic techniques, less addictive medications, cognitive behavioral therapy, and continuing education could help combat this destructive and fatal epidemic. Physicians who suspect their patients (or in my practice, patient’s parents) of misusing their opioids need to have options to treat/prevent/report these patients before escalation occurs.

Thoughtful legislation can help us combat this crisis, without hurting our ability to appropriately treat our patients. Laws should help physicians and other healthcare providers diagnosis and treat this disease, not add obstacles to appropriate patient care.

 

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