New Controls on Opioid Prescribing

As discussed in my last blog entry, prescription monitoring programs will help diminish our present-day epidemic of prescription opioid addiction, but these PMPs are just a start. State and federal governments are passing other laws, with the intent to reduce pain pill addiction.

For example, over the summer, Ohio enacted legislation aimed at physicians who primarily see patients prescribed opioids for chronic pain. Doctors prescribing opioids for more than 50% of their patients are now required to take periodic continuing medical education classes about the safe prescribing of opioids. These physicians are required to take a minimum of twenty hours of training every two years. Ohio also now says that physicians who own pain practices need to register with their medical board and undergo site inspections, as well as comply with patient-tracking requirements. Six other states now mandate doctors get yearly continuing education on pain management and the safe prescribing of opioids to maintain licensure from their medical boards.

Some doctors protest these measures, but this training is intensely needed. More than ten years ago, CASA (Center on Addiction and Substance Abuse at Columbia University) did a study that showed physicians are poorly trained to recognize and treat addictive disorders. Of doctors who were surveyed about the training they received in their residency programs, thirty-nine percent received training on how to identify drug diversion, and sixty-one percent received training on identifying prescription drug addiction. Seventy percent of the doctors surveyed said they received instruction on how to prescribe controlled substances. (1)

These findings are appalling. Thirty percent of doctors received no training on how to prescribe controlled substances in their residency programs.  Nearly a third of the doctors leaving residency – last stop for most doctors before being loosed upon the populace to practice medicine with little to no oversight – had no training on how to prescribe these potentially dangerous drugs. Sixty-two percent leaving residency had training on pain management. This means the remaining thirty-eight percent had no training on the treatment of pain.

 These doctors weren’t in specialty care. They were in family practice, internal medicine, OB/GYN, psychiatry, and orthopedic surgery. The study included physicians of all ages (fifty-three percent were under age fifty), all races (though a majority at seventy-five percent were white, three other races were represented), and all types of locations (thirty-seven percent urban, thirty percent suburban, with the remainder small towns or rural areas). This study shows that medical training in the U.S. does not, at present, do a good job of teaching doctors about two diseases that causes much disability and suffering: pain and addiction.

 Despite having relatively little training in indentifying and treating prescription pill addiction, physicians tend to be overly confident in their abilities to detect such addictions. CASA found that eighty percent of the surveyed physicians felt they were qualified to identify both drug abuse and addiction. However, in a 1998 CASA study, Under the Rug: Substance Abuse and the Mature Woman, physicians were given a case history of a 68 year old woman, with symptoms of prescription drug addiction. Only one percent of the surveyed physicians presented substance abuse as a possible diagnosis.  In a similar study, when presented with a case history suggestive of an addictive disorder, only six percent of primary care physicians listed substance abuse as a possible diagnosis. (2)

Besides being poorly educated about treatments for patients with addiction, most doctors aren’t comfortable having frank discussions about a patient’s drug misuse or addiction. Most physicians fear they will provoke anger or shame in their patients. Physicians may feel disgust with addicted patients and find them unpleasant, demanding, or even frightening. Conversely, doctors can feel too embarrassed to ask seemingly “nice” people about addiction. In a CASA study titled, Missed Opportunity, forty-seven percent of physicians in primary care said it was difficult to discuss prescription drug addiction and abuse with their patients for whom they had prescribed such drugs.

From this data, it’s clear physicians are poorly educated about the disease of addiction, as well as the safe treatment of pain. Medical schools and residencies need to critically re-evaluate their teaching priorities to include training in pain management and addiction. Until that can be done, states need to mandate yearly training for physicians on these topics, because most practicing physicians never got adequate training on these topics.

Most doctors are not happy about these government mandates. It’s human nature to resent being told you need more training, especially if it’s at your own expense. It’s difficult to get time off work for trainings and it’s inconvenient. Yet the alternative – no increase in training for practicing physicians – isn’t acceptable. The addiction rate is too high in this country to ignore, or to avoid taking actions.

Not all of the new state mandates are good ideas.

The state of Washington passed a law in 2010 that took effect in July of this year. It says only pain management specialists can prescribe more than the equivalent of 120mg of morphine per day for a patient. Non-pain management doctors cannot prescribe more than this, by law.

I think it’s alarming when lawmakers set dose limits for any medication. I don’t know of any other medication in any other state that has a dose limit set by non-physicians.

I assume Washington’s lawmakers had good intentions. They’re concerned about the rising numbers of opioid overdose deaths in their state. They based the cut-off of 120mg of morphine on a study (Annals of Internal Medicine, Jan 19, 2010) that showed patients taking more than 100mg of morphine, or its equivalent, were nine times more likely to have a drug overdose than those prescribe 20mg or less. But these lawmakers aren’t equipped to understand the real life complications that may occur due to this law. Government officials have already admitted they don’t know how patients will be able afford to see pain specialists, or even be able to find a specialist, since there aren’t enough pain specialists in that state. The government’s website explaining the new rules (3) also admits there are no lists of physicians pain specialists. I couldn’t find the state’s definition of a “pain specialist” on this website, so there will be confusion as to what this even means. If it means only doctors who are board-certified in pain management, that will surely be a very small number. Some doctors have said they will avoid prescribing opioids at all, given the additional regulatory burdens.

Other critics of this new law say it gives false gives reassurances to patients and doctors that doses under the 120mg cutoff are safe. We know that’s not true. Many times the danger lies in other medications, like benzodiazepines, that are prescribed with opioids.

This same law goes into great detail about how pain patients are to be screened before opioids for chronic pain are started, and how patients who are prescribed opioids are to be managed. Patients must be screened for past addiction, and for depression and anxiety disorders. The law outlines how patients are to be followed by their doctors. Washington’s lawmakers also mandate random urine drug screening of patients being prescribed opioids, and written patient agreements. The law gets in to specific details about what needs to be in the patient monitoring agreement.

Some doctors feel the government has overstepped its bounds and will interfere with physicians’ clinical judgments. Patients are already complaining that they have great difficulty finding doctors who will prescribe opioids to adequately treat their pain.

I support most legislation that helps physicians identify and treat opioid addiction, but I think Washington’s law has gone too far. Balanced, rational decisions are urgently needed. If we over-react out of fear, the pendulum will swing too far to the other side. Over-regulation could have unintended consequences including having patient in acute or pain or with cancer pain unable to get an adequate prescription for opioids.

  1. 1. Missed Opportunity: A National Survey of Primary Care Physicians and Patients on Substance Abuse, Center on Addiction and Substance Abuse at Columbia University, April 2000. Also available online at http://www.casacolumbia.org  
  2.  Under the Rug: Substance Abuse and the Mature Woman, Center on Addiction and Substance Abuse at Columbia University, 1998. Available online at http://www.casacolumbia.org
  3.  http://www.doh.wa.gov/hsqa/Professions/PainManagement/
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3 responses to this post.

  1. Posted by dbc92912 on November 7, 2011 at 10:02 am

    The one thing you need to remember is that not all physicians are moral. I’ve met them. Some seriously know they are running pill mills and are in it purely for the money. Otherwise, I agree with YOU.

    P.S. Typo:
    “Other critics of this new law says that it gives false gives reassurances to patients ..”

    Reply

  2. Posted by steph on April 11, 2016 at 8:41 pm

    I don’t think this law helps the patients with chronic pain. I have ended up having to take
    An ambulance ride because the doctor left me with a patch that didn’t help with my chronic pain. I was actually in more pain. Well 150.00 later my doctor put me on 30mg 2xa day and I was better only to find he changed it to Embeds so far it has unfortunately left me in my bed in pain…and I am having a lot of difficulty walking. Why. Can’t the doctor’s help the people with extream pain. I feel like a Ginny pig at this point. Just stick with what helps the people with chronic pain. At this point I don’t have a quality of life because the government is taking that away from me.

    Reply

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