A recent study published in Annals of Internal Medicine offers a shocking glimpse at just how broken our health care system is when it comes to delivering help to people battling addiction.
The research showed that among 3,000 people who suffered nonfatal overdoses while being prescribed opioids for pain over a 12-year period, 91 percent of them continued to be prescribed opioids, with 70 percent of them continuing to get painkillers from the same provider. Two years later, those who continued to be prescribed high levels of opioids after the first overdose were twice as likely to have a second overdose. (1)
In an accompanying editorial, Annals called the findings “astonishing” and a glaring missed opportunity to get people who need help into treatment. “The overdose event was a potentially pivotal moment for patients and physicians, a moment when intervention might be both possible and welcome.” (2)
While a knee-jerk reaction to the findings would be to place blame on doctors who continued to prescribe the pain pills, it’s really not that simple.
Here are five problems the study’s authors identified as obstacles physicians face to getting people who overdose into treatment, and some suggested solutions for getting past them.
1. Often, doctors never find out the patient overdosed.
Solution: Treat opioid overdose as a public health problem, with mandated reporting of overdoses much the same as mandated reporting of rare communicable diseases. “As noted by the authors, there are currently no widespread systems in place, either within health plans or through governmental organizations, for notifying providers when overdoses occur,” Annals wrote in its editorial. “Until such systems exist, providers will be left to act with dangerously limited knowledge. They will be unlikely to decrease or withdraw a patient’s opioid prescription after an overdose if they have no knowledge that the event occurred.”
In the study, the authors suggest ways notifications could occur, including direct contact between the hospital emergency room where the patient is treated and the opioid prescriber. Almost every state has prescription monitoring programs that could facilitate such communications. “A more centralized approach would mandate reporting of overdoses to a department of public health to facilitate referral to substance abuse treatment or proactive notification of providers and pharmacies,” the authors wrote. “This approach may be limited because of the confidential and sensitive nature of disclosure of substance abuse disorders.”
2. When patients begin to ask for more pills, primary care physicians, being neither pain nor addiction specialists, don’t recognize that they may be dealing with an addict.
Solution: Mandate increased training for doctors prescribing opioids and integrate basic addiction and pain management education into medical school curricula. “Most providers receive little training, have few resources, and receive minimal support to address either chronic pain or addiction,” Annals wrote in the editorial. “The situation is more complicated when the conditions overlap.”
The US Centers for Disease Control and Prevention proposed updated guidelines for doctors prescribing opioids. Among them: “Providers should use their state’s prescription drug monitoring program to review the patient’s history of controlled substance prescriptions when starting opioids for chronic pain and at least every three months during treatment. Urine testing should be performed before initiation and at least annually thereafter,” according to an article in NEJM Journal Watch. (3)
3. Doctors don’t want a patient to suffer in pain and become unable to work or care for their children, so they keep prescribing and even upping the dose.Yet the study showed that most patients had a dosage increase in the week prior to the overdose.
Solution: Providers should consider other pain management methods and also warn patients of the risks of long-term opioid use.
In a position paper published last year by physicians attending a National Institutes of Health workshop on the role of opioids in the treatment of chronic pain, the authors warned, “Data to support the long-term use of opioids for chronic pain management are scant.” (4) The paper reported that during a workshop on the issue held by the National Institute of Health, “speakers stressed the need to use treatment options that include a range of progressive approaches that might initially include nonpharmacologic options, such as physical therapy, behavioral therapy, and complementary and alternative medicine approaches” first. “The use of and progression through these treatment methods would be guided by the patient’s underlying disease state, pain and risk profile as well as their clinical and functional status and progress.”
In the proposed CDC guidelines for prescribing opioids, it is suggested that doctors discuss the benefits and risks of continued opioid therapy every three months.
4. Some doctors do recognize addiction when they see it, yet they find themselves in a Catch 22 – if they don’t keep prescribing the painkillers, the patient may feed his or her addiction with street drugs, such as heroin.
Solution: Initiate better patient monitoring measures.
“Realistic expectations about potential harms from various treatment options should be discussed with patients as well as relatives and caregivers,” the authors of the Annals position paper reported. “Communication options should be available to discuss evolving concerns; for example, adverse events and side effects might be monitored regularly and reported to the clinician between regularly scheduled visits by using the Internet or other communication channels.”
5. Emergency rooms aren’t equipped to whisk a patient brought in for an overdose into treatment, even though the patient may be willing to go into rehab at that time.
Solution: Institute systems to identify patients seeking care for problems directly related to substance abuse, such as abscesses, endocarditis, or overdose.
“Research suggests that patients hospitalized for conditions related to substance abuse exhibit high readiness to change and that hospital-based interventions that provide in-reach services and referral can successfully discharge patients directly to the appropriate services for addiction treatment,” Annals wrote in its editorial. “This model turns a potentially devastating event into an opportunity for hope.”
1. Larochelle M., et al. Opioid Prescribing After Nonfatal Overdose and Association With Repeated Overdose. (2015, Dec. 29). Annals of Internal Medicine. Retrieved Jan. 3, 2016, from https://annals.org/article.aspx?articleid=2479117
2. Editorial. Annals of Internal Medicine. (2015, Dec. 29). Follow-up to Nonfatal Opioid Overdoses: More of the Same or an Opportunity for Change?
3. Young, Kelly. CDC Proposes Updated Guidelines for Opioid Prescribing. (2015, Dec. 18). New England Journal of Medicine. Retrieved Jan. 3, 216, from https://www.jwatch.org/fw110969/2015/12/16/cdc-proposes-updated-guidelines-opioid-prescribing
4. Reuben, D. et al. National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain. (2015 Feb. 17). Retrieved Jan. 3, 2016, from https://annals.org/article.aspx?articleid=2089371
David W. Newton is a board certified pharmacist and also has been a board member for boards of examiners for the National Association of Boards of Pharmacy since 1983. His areas of expertise are primarily pharmaceuticals as well as cannabinoids. You can read an article about his expertise in CBD on the National Library of Medicine.