SOUTHERN INDIANA — Medical practitioners who recognize their role in helping stem the opioid abuse crisis in America are educating themselves and their colleagues on responsible prescribing.
While advocates of the checks say it's a leap in the right direction, it's not yet a perfect system.
According to the Centers for Disease Control and Prevention, there were 259 million opioid prescriptions written in the United States in 2012 — enough for every American to have at least one. There were also more than 165,000 opioid overdose deaths across the nation.
The numbers indicate that a responsibility to help reduce abuse lies, in part, with practitioners who prescribe opioids. Many doctors are tackling that responsibility by educating themselves on how the drugs can be used more safely and by screening patients more thoroughly.
In the face of the drug epidemic, the Centers for Disease Control and Prevention issued guidelines in March 2016 regarding long-term pain management, excluding that for cancer patients and end-of-life care.
State regulations also dictate how opioids should be dispensed. A new law enacted last April states that practitioners should not prescribe more than a seven-day supply of opioids for children less than 18 years of age and for adults who have never been prescribed the medication.
Patients also have the option to request less than the seven-day supply.
Dr. Eric Yazel, emergency physician and Clark County Health officer, said the key to prescribers deterring opioid abuse is not only following regulations, but also using common sense. The goal is consistency in prescribing among physicians.
“A third party should be able to look at a chart and a diagnosis, tests, and they should be reasonably matched with the level of pain control [patients] get,” he said.
Yazel said he thinks that's where things got 'off kilter' with over prescribing in the past. A few years ago, it was more common for him to see a patient in the ER with no means on their chart to link the amount of pain medication from another doctor to a condition that warranted it.
HOW WE GOT HERE
In the late 1970s and early '80s, opioids were used primarily for patients with cancer or palliative care, said Dr. James Murphy, a board-certified pain specialist who is also certified in addiction medicine.
However, a push in the 1990s by drug companies and the government led to more aggressive prescribing by physicians, he said.
“The drug companies over-marketed the medications such as Oxycontin and they underestimated the addictive potential for these drugs,” Murphy said. “As a result, many well-meaning physicians, in an effort to treat pain aggressively, over prescribed the medications.”
Hence many more pills were out in the communities, opening the door to misuse, abuse and addiction.
“When the pills are used for non-medical reasons or they're used by somebody who's at risk for developing addiction, then the crisis begins,” he said.
CHANGING PERSPECTIVES
Both doctors said it's important to screen patients by using the Indiana Scheduled Prescription Electronic Collection and Tracking program (INSPECT) and the Kentucky Prescription Monitoring Program (Kasper.)
But the screening goes further, including risk assessments and urine testing for drugs. Murphy said he has to make sure patients are adequately treated for pain, while doing so responsibly.
“The first thing I want to determine is why they have pain or need the medication,” he said. “Then I have to ask, what are the best and safest ways of treating it.”
Things like heat, ice and over-the-counter medication should be tried first, Murphy said. If those don't work, he may start a patient on a trial run with an opioid, after initial screening.
“Before I would give you a Motrin, I would ask, are you allergic to Motrin,'” he said. “So before I'd want to give you an opioid, I'd ask certain questions. Have you ever had a problem with drugs or alcohol or opioids? Do you suffer from any psychological issues? Do you live in a house where people abuse drugs?”
In the ER, Yazel may start with initial alternatives like ibuprofen, naproxen, or gels like Biofreeze. For more acute pain, he might prescribe Ketamine, a non-opioid, for patients who are higher risk or have an addiction.
If a person has a serious injury but exhibits risk factors, Yazel carefully goes over all the options with them. If they go the opioid route, it's conditional.
“I do feel like the onus is on us to do our homework on that,” he said. “That's when I say there will be no 'my prescription fell down the toilet,' or anything like that. You have to uphold the rules that I give you and have a diagnosis that matches it.”
MOVING FORWARD
Yazel said while he thinks the guidelines and laws have been successful in curbing loose prescribing, reigning it in now isn't going to solve the whole issue. The rise in heroin abuse is a direct fallout of the clampdown on pills from doctors, he said.
“So what our next challenge is, as we're working our tails off to try to meet the heroin epidemic head-on” is to stay alert to what's next, he said.
Yazel also doesn't want doctors to lose sight of the opioid crisis.
“Right now, you hear 'opiate, opiate, opiate,'” he said. “Five years down the road, when hopefully that's not as big of a subject, are [prescribers] going to start back-sliding, saying 'I'm too busy to look up that report or sit down with [a patient]?'
“As physicians, we're partially responsible for creating this problem, the responsibility is on us to try to clean it up as best we can.”