Opioid Epidemic

[Donnie]

Since this is a forum of mostly doctors, I am curious about your views on the opioid epidemic.  An article I read last year showed that between 2007 and 2012, 780 million hydrocodone and oxycodone pills were shipped to WV, or 433 pills for every person in the state.  Whenever I mention this article to someone, I always understate the number of pills shipped per person because it is such a staggering number.

While there is no doubt that the pharmaceutical companies and distributors have significant blame here, I wonder why there aren't more safeguards in place with both the prescribing doctor and the pharmacy.  I am sure there are unscrupulous doctors prescribing these pills, but why do they do it?  Are they paid under the table to write these prescriptions?  It seems like something is seriously broken here, and I personally don't think stepping up law enforcement against addicts solves much.  What are your thoughts on how this happened and how we should fix this problem?

 

[ScientistPhysician]

I honestly believe the solution will be better drugs.  There are new mu opioid receptor biased agonists in development that selectively stimulate G-protein signaling over arrestin activity. There was an amazing paper about this in Nature last year (largely lead by Brian Kobilka's group at Stanford). Animals who got the drug showed selective analgesia without affecting respiratory rate, GI motility, or dependence behavior.

 

I just don't see your average entitled, whiny american patient showing the self-control and humility needed to curb their dependence. Getting through pain is hard enough, couple that to the reward pathways normally activated by opioids, it's asking too much for these people to trade their positive high for pain.

 

[Hatton]

This problem has been festering for years.  People seemed to think they were not a "drug addict" if it was a prescription medication.  Some of the problem is unethical money hungry docs and pharmacists.  Some of it is JCHACO making pain the fifth vital sign.  Up until recently it was hard to track how many opiate prescriptions a patient was filling. This helps when patients are filling prescriptions legally.  Drugs of abuse really seem to cycle and the trend seems to be heroin and fentanyl.

[Doctor Money Matters]

Dont you think pharma has a big role here? Encouraging off label use and higher doses than normal from their drug reps. Bribing physicians.

https://www.usnews.com/news/us/articles/2017-08-03/insys-takes-45-million-charge-to-settle-illinois-opioid-lawsuit

There are some players in the pharma industry that are no better than the mexican drug cartels or Pablo Escobar, yet we will never see them go to jail even though they probably have caused more damage in a shorter time.

[ReFinDoc]

Many physicians are "running for the border": trying to shore up Primary care practices by easy prescribing. Many Pain Specialists are losing procedure (EPI, facet injections, SCS) revenue and looking to bring in  cash.

Relentless selling by Big Pharma .

The Decade of Pain BS.

Teenagers using  prescribed opioids.

Internet trading of narcotics.

[StarTrekDoc]

Tell Phillip Morris and Inbev too on their products too...not going to happen.

Medical community definitely didn't help with the pain vital sign and the 2000s push of no limits to opioids for pain mananagement. Couple that with methadone clinic without oversight on lack of weaning protocols. ..are pushed legal addiction.

[ENT Doc]

Incentives created this problem, among other things.  As hatton said, by requiring a pain assessment on every patient the Joint Commission effectively made pain another vital sign.  And when patient satisfaction scores came more into focus a doctor would be damned if they didn't address even that 1/10 pain.  Doctors also don't want to be bugged by the complaining patient and prefer to avoid a late night phone call from a patient asking for more meds.  It's like the mother who won't listen that antibiotics aren't going to help her kid's ear infection.  When you're behind, would rather a satisfied mom who will leave a good review, and just don't have the time to spend 5 minutes educating them through their belligerent requests (thanks EMR) the incentives are there to pick ease over quality.

[MaxPower]

About 10 years ago the AAOS went on a tirade about how orthopedic surgeons weren't adequately addressing patients' pain. So up went the number of prescriptions and amount of narcotics in each prescription. Then about a year or so ago they came out and berated us for overprescribing narcotics. So which is it?

It's also a generational thing. A lot of young patients are just wimps and want to take a pill for everything. Just last night I had some whiny post op patient call because he was in so much pain after a de Quervains release (soft tissue procedure that some docs do in a procedure room in the office). Meanwhile, didn't get a single call from the 84 year old lady whose distal radius I fixed and who got half the dose of norco that the 32 year old got.

Press-Ganey is another culprit. I remember In residency on the trauma service getting harped at by admin because the satisfaction scores and pain control scores for the trauma patients was below average when those derelicts sent in their surveys. Well that's because we refused to write people dilaudid and OxyContin scripts for everything at discharge. In my mind the government created a lot of this problem and now they're trying to blame us as physicians. GTFO.

[Hatton]

As the pendulum swings back to we are prescribing too much opiate and we are decreasing the scripts the addicted patient is buying heroin/fentanyl and dying. The media is all over it now but I really don't see an easy answer.

[TheBossMD]

Patient satisfaction plays a role but I think lack of understanding regarding patient satisfaction metrics is also to blame. Prescribing pain meds is not the only avenue to getting good satisfaction scores. If more doctors and health systems really understood how the metrics work then there wouldn't be as much pressure.

[jfoxcpacfp]

Donnie wrote:

I am sure there are unscrupulous doctors prescribing these pills, but why do they do it?  Are they paid under the table to write these prescriptions?

Click to expand...

MONEY - read American Pain about the original mega-pill mill in FL. People would load up tour buses from Kentucky and Tennessee to come down, like a tourist junket. It was incredible how much the business owners and these doctors were making, until they finally were brought down. And it couldn't even be prosecuted without changing the laws, which took a lot of government coordination.

[Dr.V. Investor]

I can go on ranting on this. I am pcp and I deal with this daily.  I love what I do but this is one area I despise.  There was an article in WSJ not so long ago stating that 53% of opiates are coming from us.  for pain specialists in forum, though this is not finances related, I do ask for help.

1.  I agree that making pain a 5th vital sign worsen this problem.  Why do we need to address this at every visit? Discussing this alone, can take up the entire visit.  what about the rest of a patient's issues?

2.  Why do we need prior auth when we prescribe diclofenac gel or stronger nsaid when there is no need for prior auth to prescribe narcotics?

3.  I have prepared visuals for my patients about tolerance, dependence and abuse- they will fight you on this.  It is a struggle to taper down narcotics they have been used to. Patients can give you sob stories and be manipulative. I have been told by a patient that I treat them as a number and not as a person when I told them I will decrease their narcotics.

4.  addiction is a disease, we need to treat them for it. previously, when a patient violates pain contract, we discharge patients, now, we cannot.

5.  Patient satisfaction surveys are now becoming part of your compensation plan to determine the "quality" of service you provide.

I have yet to personally meet a physician in my field who do it for money.  I could see why it is easier to write what a patient wants when you have 20+ patients to see.  I am  inheriting a load of patients from a good physician, who was very liberal in prescribing.  I have a lot of cleaning up to do.  If you have suggestions, I am welcome to it.

[SValleyMD]

My fix:

1. Only certain docs can prescribe opiates

2. Large hospitals have a pain service that covers inpt day and night pain needs

3. National or at least state database that requires review before filling (some states have this)

4. Big change would be no for-profit pain clinics (which in my town are run by midlevels and total pill factories). ? Maybe govt run pain clinics? (Ugh)

My PRN med list includes: morphine, fentanyl, oxycodone ect just so I don't get another call in the middle of the night on my q4 call schedule saying so and so is still "in pain."

Hard to change that culture with pts, nurses, admin and docs

[Hatton]

Oddly since I retired from OB I hardly have any drug addicted patients. Really a sad commentary on the topic.

[hightower]

I always find it amazing how easy it is to prescribe an opioid and how hard it is to prescribe suboxone.  It should be the other way around.  There's a big profit motive at play here for sure.  I don't know what the ultimate solution is, but I think tight regulation of opioid prescriptions seems smart to me.  I work at an outpatient opioid treatment center on a part time basis and almost every patient I ask tells me they got started with legally prescribed opioids from their doctor or the ER or after a surgery.  Now they are required to jump through a million hoops to get placed on Suboxone (which is an excellent drug for treating opioid addiction btw) and it's very costly and time consuming for them to stay on it  We need to make the treatment for opioid addiction more accessible and we need to make the initial prescribing of opioids less accessible.  I don't know what the best course of action is, but certainly people should be warned like crazy that they are being prescribed a highly addictive substance and doctors should be forced to jump through hoops to give it out.  Special licensing? Special documentation?  I don't know, but opioids need to be difficult to prescribe so as to discourage their use except for in the most necessary of cases.  Opioids should be as tightly regulated as "medical marijuana" IMHO.  Why isn't this already the case?  I would bet greed has pretty much everything to do with it.  It's a legal drug cartel and people are making a killing profiting from it.