Physicians and opioids: Part of the solution, but challenges ahead

James S. Gessner, MD
James S. Gessner, MD, President Massachusetts Medical Society, Guest Contributor

With more than 200 million prescriptions for opioid medications being written every year, it’s hard to escape the notion that physicians must share some of the blame for creating the opioid epidemic facing the nation.

The criticism has come from many quarters. Editorial writers have pointed the finger of blame, as have high-ranking elected officials. More than a third of the American public think doctors are at fault, and even members of our own profession have acknowledged the unwitting complicity of physicians.

There’s no denying it. Despite our well-intentioned motivation to care for our patients and treat their pain, we physicians have played a role in this crisis.

What may be getting lost in the current conversation about opioids, however, is the change that has occurred within our profession. Physicians have recognized the damage done and are responding, and it’s important that patients and our colleagues know the extent of what we are doing — and what resources are available.

The list is long: collaborating with state officials to develop strategies; educating patients about safe storage and disposal of medications; convening policymakers and experts in forums and summits; and encouraging use of prescription monitoring programs.

Perhaps our most notable efforts have been educating our colleagues. In 2015, our state medical society was among the first in the nation to issue prescribing guidelines, subsequently adopted by the Board of Registration in Medicine and incorporated into its comprehensive advisory to physicians on prescribing issues and practices.

Those guidelines were followed by continuing medical education courses on opioids and pain management, made available (and still) free to all prescribers. From May of 2015 through the end of February 2017, more than 9,100 individuals have completed more than 25,800 course modules on the topics. The numbers are testimony to how physicians are responding.

Additionally, together with the deans of the state’s four medical schools and state health officials, we have brought opioid education to the next generation of physicians by developing core competencies for medical students, to teach them early in their careers about pain management.

The advocacy of partial-fill legislation, to reduce the amount of drugs subject to diversion, and the convening of political and healthcare leaders to push for more medication-assisted treatment have been other physician-led efforts.

Hospitals and medical schools have raised their level of response as well.

The University of Massachusetts Medical School has implemented Opioid and Safe Prescribing Training Immersion for medical and nurse practitioner students, including interactions with standardized patients, group sessions with patients in recovery, and hands-on overdose care and naloxone rescue.

Boston Medical Center, in collaboration with the Department of Public Health and Boston Public Health Commission, with its Faster Paths to Treatment Opioid Urgent Care Center, and the Boston University School of Medicine, with its Safe and Competent Opioid Prescribing Education program, are in the forefront of substance abuse disorder treatment. Massachusetts General Hospital, Brigham and Women’s Faulkner Hospital, and Beth Israel Deaconess Hospital Plymouth are among others engaged in significant efforts.

The medical community is responding, and there is progress. In separate studies, the Massachusetts Department of Public Health, athenahealth, and the Cambridge-based Workers Compensation Research Institute have all recorded drops in prescribing.

Despite these efforts, and those of state government, public health officials, law enforcement, and many others, deaths from opioid overdoses have reached record numbers in the Commonwealth and the nation, caused in large part by illegal, synthetic fentanyl. Here’s another ominous sign, revealed in a recent national poll: more patients are taking opioids.

The rising numbers of overdoses show just how difficult it will be — and how long it might take — to claim some measure of success in reversing this epidemic.

Yet while struggling to prevent and reduce addiction, physicians face another test.

Whether fearing sanctions or deciding it to be too complicated, many physicians have cut down on prescribing opioids, and some have stopped prescribing altogether. The result: patients who truly need help aren’t getting the care and relief they need.

How many patients are in this situation is uncertain, but they are beginning to be heard. What is certain is that the challenges of pain management just became a lot tougher — for both the patient and the physician.


The Opioid Crisis in America

Register for this free self-paced course here

Every day in the United States more than 1,000 people are treated in emergency departments for not using prescription opioids as directed. In 2015 more than 30,000 people died from overdoses involving prescription opioids. This course challenges preconceptions about who can become addicted to opioids, attempts to reduce the stigma that exists around addiction in general, and to help people learn about the multiple pathways to treatment.

Comments:

  1. Joni Rains

    Thank you for this discussion. I hope those who are responsible for carrying this out will look at this differently now.
    I am a chronic pain patient. I have had debilitating pain for 17 years. My condition is rare. There are no known cures for my pain, probably because my condition is rare. I have been prescribed opioids for 8 years. I have reached an amount in which my Pain Doctor and I have worked on for a long time. I am able to cope. I live my life the best I can, which is limited, but I CAN FUNCTION AND COPE WITH MY EXISTENCE as a human being.
    This not the case anymore.
    My Pain doctor is under such pressure to cut back and /or drop patients, he was forced to drop my dosage slightly. I am now a victim. I am suffering. I can’t believe that someone who doesn’t know me and my life, can decide that I should suffer MORE each and every minute of my life. THIS IS A NIGHTMARE.
    I understand that when a physician takes an oath to cause no pain and help those who need are lying. I am now in more pain. I am not able to function. I am in too much pain as I write this now.
    I am not an addict who seeks out a high. I do not experience a high on my medication. I am probably addicted to my medication, as I am probably addicted to my anti-depressant.
    I take my pain meds as they are prescribed.
    I am in excruciating pain with this small change in my dosage.
    Please give me my life back, as small as it has become, it is my life.

  2. Marcia Lester

    As a patient, and, as a now disabled RN with chronic pain, I have been able to reduce my use of opioid pain relievers. I have used acupuncture, yoga and physical therapy. I have taken prescription anti-inflammatories and anti-inflammatory topical gels. However, only physical therapy is covered by insurance and Medicare. Now, Medicare and insurance have denied the use of the anti-inflammatory medication, I use. Yes, physicians must take a larger role in controlling the use of opioids. However, if a patient cannot afford other proven options to reduce their pain, what are they to do? Both, our government and the insurance companies, must take a larger role in fighting the opioid epidemic. Frankly, I don’t see this happening, at all.

  3. Juju Bail

    Thanks for your help. Can you please provide information on orthostatic hypotension.

  4. Adam

    Excellent,
    I’m happy to see that research in addiction treatment is finally starting to catch up to the true complexity of the problem.
    It’s unfortunate that it took so long and that so many have gone untreated or under treated thus far. The current epidemic has really highlighted this.
    I write for cokeclear.com, we try to keep track of this issue and hopefully enable family members to identify the early sighs of addiction.

    Regards,
    Adam

  5. Rachelle Ditzian

    Thank you for this article. I think it’s really great that physicians are getting involved and sharing responsibility for the opioid crisis. However, that being said, I believe addiction is far more complex than simply having access to a substance. For example, most people have access to alcohol and yet not everyone gets addicted to it.

    I appreciated that you acknowledged the rise of a new problem: the increased difficulty for patients who are truly experiencing pain to get the meds they need. Opioids can be a very important and effective part of pain management for many people. I am hoping that most physicians will lean towards increased patient education on the potential for addiction rather than ceasing to prescribe opioids.

    Thanks again.

    Best regards,

    Rachelle Megan

    • Dr. James Gessner

      Ms. Ditzian: Thank you for your comments on the essay and your acknowledgment that physicians are acting to address the opioid crisis. You have captured the key issue physicians face when treating pain: how to balance the risk of addiction while providing help for those patients who truly need relief. Achieving that balance requires the continuing education of both prescribers and patients, and the good news is that many in the medical community are responding positively. With millions of patients experiencing chronic pain, however, prescribers must be alert that, in addressing the opioid epidemic by reducing the number of prescriptions, the pendulum doesn’t swing too far in the opposite direction.