Opioid prescribing: Doctors need to do a better job, but they can’t do it alone

I recently took a three hour online course on something I learned to do when I was a medical student.

And I thought it was something I had been doing fairly well for the past 20 years.

New regulations have come down requiring all practitioners to take a CME-certified course on safe and effective management of opiates for acute and chronic pain. This has clearly come about in response to revised prescribing regulations and the tragic epidemic of opioid overdoses and misuse/overuse, so it’s not a bad thing to help us learn to do this better.

Long, long, (long) ago, when I was a medical student, I remember a jaded third-year resident during the last weeks of his final year, telling the students and interns on his team, “Remember, it takes 30 seconds to write for Tylenol with codeine, but 30 minutes to not write for Tylenol with codeine.” He was referring to the time-consuming discussions — and possible arguments — that could ensue if doctors tell patients they can’t have the drug.

Not a great foundation for sensible prescribing.

A swinging pendulum

I dutifully sat in my office yesterday watching the PowerPoint slide deck scroll by, listening to the authors talking about pain, where it came from, how to treat it, what our options were, how to do it well, how to do it better.

In the end, however, it felt like it’s becoming nearly impossible for us to do this safely and efficiently, or that if we continue to do it in the manner we’re doing it now, we’re doing it all wrong.

The pendulum has swung in pain relief, and the environment we practice in went from one where we hardly ever used these medicines, to where we were told we were massively under-treating people’s pain and that we should always treat until their pain was gone, to now it feels like it will take an hour or more to ever prescribe opiates again.

Suddenly, we as providers are responsible for the safe disposal of medications, ensuring that patients are locking them up safely at home, and somehow being able to use a multitude of unvalidated instruments to try and determine whether patients are diverting these medicines, misusing them, or simply getting inadequate relief.

My objection to this is not to the fact that we need to do a better job of prescribing these challenging medications. I agree we have probably created a system where we overprescribe, and this has led in some part to the opiate problem facing our nation.

But the problem is, this very intensive effort, these huge involved processes of trying to figure out whether this is the right medicine, whether the pain medicine is working, whether the patient may be doing something we don’t want them to be doing — we have to do this pretty much all on our own, as we have had to do for almost everything we do.

Prescribing is an art

Look at prescribing medicines for simple conditions like high blood pressure and diabetes; done right, even this requires intensive amounts of effort. It’s easy to simply prescribe and send someone off into the world, but we all know that doing this doesn’t lead to much improvement in their blood pressure or their diabetes.

How often have we started a patient on a new blood pressure medication, thought we had carefully explained to them the risks, benefits, alternatives, possible side effects, how to take the medicines, all that good stuff, only to have the patient return for a blood pressure check the following month and tell us, “Doc, I finished the bottle, so I thought I was done”?

I think I learned a lot from watching all those slides, and I’m hopeful that I will become a better provider prescriber of opiates, more thoughtful in my choice of medicines, more judicious in dispensing amounts, more rigorous in ensuring compliance and follow-up, but I can’t do this alone.

None of us can.

Just as managing all of the other complex medical conditions our patients have requires the coordinated efforts of a team, it seems like the patient-centered medical home offers an opportunity to address this problem in a better way than simply requiring practitioners to watch a PowerPoint presentation and promise to behave.

We alone can’t ensure that patients aren’t going to be leaving dangerous medications sitting unsupervised on their kitchen tables, and it’s unfair to expect us to do that.

More resources are needed

If this is a public health emergency (which I think it is), then the resources of the entire health care system need to be brought to bear on the problem.

It’s great to remind me that there are other options besides opiates for pain, and nudging me to try and always use the lowest dose and the lowest number of dispensed pills, to continue efforts at nonpharmacologic treatments, and to work to get my patients off of these medicines. These are always good ideas.

But so much of each patient’s life, and so much of their pain, takes place outside of the office, away from my sphere of influence, that we need more help, we need more resources, we need that entire team helping to take care of our patient.

I remember the first time a patient told me, after I had been taking care of her chronic pain with opiates for many years and dutifully refilling her prescription every month, that she’d had an epiphany, a change of heart, and she had been taking every prescription I had given her for the past few years and selling it on the street.

Being a fairly new provider, I was sort of shocked, and it never would have occurred to me that she might be doing this. But she was an exception; most people don’t come to us and tell us they’re doing this, and a lot of these efforts for us to attempt to discover whether this is happening erodes part of the relationship between the patient and the provider.

The education sessions we went through reinforced over and over again that we are not supposed to be acting as drug enforcement, police, judge, or jury — they were only trying to do what’s best and safest for all patients.

We need to build a system that allows this to happen in a way that helps us get our patients the care they need, without overburdening the providers with lots more forms to fill out, testing to do, outreach into the community that we’re incapable of doing on our own or with our limited resources.

Maybe we make drug testing mandatory, maybe we insist on random pill counts all the time, maybe we require pharmacists do a home inspection, maybe we insist that a community-based organization involve the patient in activities to help alleviate their pain.

But our patients are hurting, and we need to make sure we don’t add so much burden to the providers that they’ll never choose an option that some of our patients desperately need.

The bottom line? We prescribe too many opiates; we prescribe not enough opiates. We prescribe them in the right situations; we prescribe them in the wrong situations. We trust our patients; we don’t trust our patients. Our patients trust us; our patients don’t trust us.

But all we can do is try to do our best, try to do no harm, try to alleviate pain as best we can, and work together to create that better health care system we know all know is out there. Somewhere.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

Image credit: Shutterstock.com

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