When it comes to our country’s opioid epidemic, much is resting in the hands of the nation’s family doctors. And at the American College of Physicians’ Annual Internal Medicine Meeting in April 2017 in San Diego, the painkiller addiction issue indeed took center stage. A freelance journalist for Foundations Recovery Network attended the conference this year.
Not only did Anthony Fauci, director of the National Institute of Allergies and Infectious Diseases, address the epidemic in his keynote address, but safe opioid prescribing was also offered as a for-credit, pre-convention course.
During the four-hour long SAFE Opioid Prescribing session, doctors learned strategies for discussing a patient’s addiction risk history, assessment tools, fundamentals of addiction, and the importance of educating the patient about potential dangers when prescribing opioids.
“Unless you have your head in the sand … you can’t be unaware of the tremendous problem of opioid overdoses in the U.S.,” said Dr. Michael Brennan of the Pain Center of Fairfield.
Brennan, who has spent three decades in the pain medicine field, said the number of opioid-related deaths in the US has quadrupled in the past few years.
“There could be as many as 40,000 deaths total this year or next,” Brennan said, adding that half those deaths likely will be from heroin. “We are the ones who control the pen and who patients still trust to convey information.”1
Considering that half of all opioids are written by primary care providers, he said it’s important they do all they can to keep even more people from becoming addicted. It’s also important patients know about naloxone, Brennan said, particularly if they are at high risk. Naloxone can reverse an opioid’s effects and bring them back from respiratory arrest.
In another convention workshop, an entire segment was devoted to how family doctors can obtain naloxone kits for patients and their families.2
Brennan said there are some extended-release and long-acting opioid painkillers that may be safer for some patients than others. He said there also are different molecular makeups among the medications that doctors should understand to better tailor their prescription to each patient.
Prior to the conference, the ACP issued new recommendations for preventing and treating substance abuse disorders.
At a news conference held during the San Diego convention, Dr. Ditin Damle, President of ACP, stressed that family doctors must become familiar with the nation’s addiction crisis. “Drug overdose death, particularly from opioids such as prescription pain relievers and heroin, is a rising epidemic. Substance use disorders are treatable chronic medical conditions, like diabetes and hypertension, that should be addressed through expansion of evidence-based public and individual health initiatives to prevent, treat and promote recovery.”
Does the Patient Have a Prior History of Substance Abuse?
The first thing any doctor needs to do when considering prescribing opioid painkillers to a patient is assess their risk. Do they have a history of substance abuse or psychological problems? Does addiction run in their family? Were they a pre-adolescent victim of sexual abuse? Are they under the age of 45? Research shows these types of patients have an even higher risk of opioid addiction.
Some doctors don’t understand what addiction really is, however. And it’s important to first understand that, Brennan said.
“What addiction is, is people who use something despite it causing harm,” he explained, adding that a physical dependency to a medication is not the same thing. Nor is a high tolerance to a medication the same as being or becoming addicted.
That is because a person can be physically dependent and yet not have a substance interfere with their daily lives. This example could be used to describe someone on opioid maintenance therapy, for example, who is holding down a job and providing for his or her family.
But all too often, “We use opioids a lot like water and treat pain a lot like fire,” Brennan said, noting that some fires get worse when you throw water on them.
Roughly 10,000 doctors and healthcare industry representatives attended the San Diego convention where the SAFE class was taught, earning Continuing Medical Education (CME) credits for their participation.
The class was created using the US Food and Drug Administration’s blueprint for the Extended-Release (ER) and Long-Acting (LA) Opioid Analgesics Risk Evaluation and Mitigation Strategy, or REMS.
Brennan said that while the workshop focused on prescribing extended-release opioids as an alternative, it’s important to remember that doctors and patients can always first try non-opioid alternatives for treating pain.
“Aberrant Behaviors” Can’t Go Unnoticed
Pain sometimes can be undertreated, Brennan said, particularly in children. He said a recent “shameful” study showed minority patients often are undertreated for pain.
That said, doctors need to be on the lookout for “aberrant behaviors” among patients on opioids.
Dr. Steven Stanos, Medical Director for Swedish Pain Services at Swedish Health System in Seattle, said he had a patient, an older woman, recently call needing a refill two days early. She said her daughter had thrown her back out so she shared some of her pills with her, and they made her feel better.
“Is that aberrant behavior?” he asked the audience. “Yes,” he replied without hesitation.
He said he told the patient “That’s nice that you’re a good mother, but that’s illegal. She could develop respiratory depression and die. Do you want that for your daughter?”
He said it’s important to speak to patients plainly, making sure they understand why certain rules are the way they are. For example, some opioid-naïve people may not be able to tolerate an extended-release opioid. It could cause respiratory depression and even death.
Stanos said patients given opioids need to be told to lock them up if they have children or anyone in the house who may try to get their hands on them. “I had one patient tell me she keeps them under her bed with her three shotguns.”
Patients who show even a moderate risk for abuse following assessment should be asked to sign treatment plans. They need to understand they are not to share their medications with anyone. Brennan also believes patients should regularly be monitored for illicit drug use with urine testing.
“You don’t want to be like that doctor in Georgia who blew off aberrant behaviors and ended up being sentenced by a federal judge,” Brennan said.
He’s referencing Dr. Nisar Piracha of DeKalb, Georgia, who will spend more than seven years in prison for prescribing painkillers to people without properly screening them first, according to the Atlanta Journal and Constitution.3
1. Argoff, C. et al. (27 March, 2017). “SAFE Opioid Prescribing: Strategies. Assessment. Fundamentals. Education.” American College of Physicians’ annual Internal Medicine Meeting, San Diego.
2. Selden, E. et al. (30 March, 2017). “Multiple Small Feedings of the Mind: General Internal Medicine, Addiction Medicine, and Anticoagulation.” American College of Physicians’ annual Internal Medicine Meeting, San Diego.
3. Coyne, A. (29 March 2017). “Feds: DeKalb Doctor ‘Preyed Upon’ Addicts With Painkiller ‘Pill Mill’” Atlanta Journal and Constitution. Retrieved May 6, 2017.
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.