This is the second in a series exploring the intersections between effectively caring for people living with chronic pain and the rise in unintentional poisoning deaths due to prescription painkillers. (The first post is here.) The series will explore the science and policy of balancing the need for treatment as well as the need to prevent abuse and diversion. This week’s story looks at clinical efforts to reduce the risk of opioid abuse and overdose while still caring for patients; the next story will explore the role of public health officials in curbing opioid abuse.
by Kim Krisberg
Since 2000, overdose deaths due to prescription painkillers in Utah have increased by more than 400 percent. By 2006, more Utahans were losing their lives to prescription drug overdoses than to motor vehicle crashes. For Dr. Lynn Webster, a longtime pain management physician, the startling numbers were a call to action. He knew that if physicians didn’t take the lead in reducing the risk of opioid-related abuse and overdose, others surely would — and a misguided or unbalanced approach could be disastrous for people living with chronic pain.
So the Utah doctor co-founded LifeSource, a nonprofit dedicated to finding solutions to the opioid problem, and began his research to find evidence-based approaches to reduce risk and prevent overdoses. His research and efforts would eventually become a centerpiece of the statewide Use Only As Directed campaign, which the Utah Department of Health launched in 2008. The campaign had two main approaches: public education and physician education. The physician education component reached more than 500 Utah doctors and “we immediately began to see a difference,” Webster said. In the years following the health department campaign, opioid-related deaths declined nearly 28 percent. Unfortunately, after funding for the campaign was cut in 2010, the death rate started to climb back up.
“When I saw those headlines in 2006 about the (Utah) epidemic of prescription drug overdoses, I knew it would be a real threat to our patients having access to treatment in the future,” Webster told me. “We as physicians have to take the lead to correct this problem…it’s our moral and ethical responsibility.”
Utah is one of many states struggling to address a growing opioid abuse and related unintentional poisoning problem. Recent data from the Centers for Disease Control and Prevention find that drug overdose death rates in the U.S. have more than tripled since 1990, and three out of four such deaths are due to prescription painkillers. Solutions are complex, especially since the majority of those abusing the drugs aren’t prescribed them directly — they get them through diversion. But a number of clinical approaches seem to be making a difference without cutting off treatment access for those who need it.
In a July 2012 study published in Pain Physician, researchers noted that a “combination of strategies is recommended to stratify risk, identify and understand aberrant drug-related behaviors, and tailor treatments accordingly.” Authors Nalini Sehgal, Laxmaiah Manchikanti and Howard S. Smith wrote:
Treatment approaches that balance treating chronic pain while minimizing risks for opioid abuse, misuse, and diversion are much needed. The use of chronic opioid therapy for chronic noncancer pain has increased dramatically in the past (two) decades in conjunction with a marked increase in the abuse of prescribed opioids and accidental opioid overdoses. Consequently, a validated screening instrument that provides an effective and rational method of selecting patients for opioid therapy, predicting risk, and identifying problems once they arise could be of enormous benefit. … Although several screening instruments and strategies have been introduced in the past decade, there is no single test or instrument that can reliably and accurately predict patients who are not suitable for opioid therapy or identify those who need increased vigilance or monitoring during therapy.
Co-author Smith, a professor and academic director of pain management for Albany Medical College Department of Anesthesiology, told me that for physicians, effectively treating chronic pain patients while at the same time reducing the risk of abuse and diversion “is very challenging…it can be a muddy clinical situation.” But physicians have to take a lead role, he said, if solutions are to be balanced.
“I’m very concerned that in the future, we may have lawmakers and regulatory bodies and others making decisions that make it even more difficult for patients that really need chronic opioid therapy,” Smith said. “It would be a terrible tragedy for patients who are doing well and having good pain relief to have this (therapy) taken away because their prescriber isn’t comfortable anymore.”
‘Physicians and education can have a large impact’
Smith said better physician education, both in pain treatment and risk reduction, will make a difference, noting that many doctors have been “somewhat starved for not only didactic knowledge in pain management, but also in clinical experience in using opioids and other pain-relieving agents.” He noted that while a lot has been written on reasonable risk management, there’s not a lot of good, rigorous literature that can say for sure what works and what doesn’t.
“We’re left with some degree of expert consensus and some degree of common sense,” Smith said.
There are a number of different clinical approaches and tools to reducing the risk of opioid abuse, diversion and poisoning, ranging from urine testing to addiction assessments to electronic state prescribing registries. The study that Smith co-authored noted that a “validated screening instrument that provides an effective and rational method of selecting patients for opioid therapy, predicting risk and identifying problems once they arise could be of enormous benefit.” (Researchers note that being dependent on an opioid to be able to function is not the same as addiction — addiction has its own physical and behavioral symptoms, such as taking out-of-the-ordinary and risky actions to obtain a drug.)
One of the assessment tools Smith uses in his practice is known as SOAPP-R, the Screener and Opioid Assessment for Patients with Pain – Revised. The 24-item tool, which Smith said has worked well in his practice, screens for the risk of opioid misuse. He also employs urine testing, though he noted that “there’s not a ton of rigorous literature to show beyond a shadow of a doubt that it needs to occur.” A review of urine testing in chronic pain patients published in 2011 in the Pain Physician journal found that “(urine drug testing) has become the standard of care for patients on controlled substances; however, the relative value of in-office screening and laboratory confirmation of those tests is sometimes unclear or controversial for physicians.”
In Spokane, Wash., family medicine doctor Glen Stream includes the possibility of random urine tests in pain management contracts between himself and his patients. The pain therapy contracts spell out terms of treatment and prescription refill schedules between patient and doctor, and Stream said the urine tests can help him pinpoint sources of opioid diversion. Primary care physicians like Stream prescribe the majority of opioids – a statistic that Stream told me is only the logical outcome of the fact that it’s primary care doctors who treat most people living with pain.
“There’s this tension between wanting to avoid overprescribing…but at the same time, we don’t want to worsen the chronic pain problem,” said Stream, who’s also board chair of the American Academy of Family Physicians (AAFP). “Finding that happy in-between where pain is being adequately treated and yet we’re addressing the misuse problem is a real dilemma.”
Stream said the AAFP opposes attempts to make continuing medical education mandatory for prescribing opioids, noting that the evaluation and management of chronic pain is already part of the core curriculum for many primary care doctors. He said creating another mandatory hoop for physicians to jump through will likely lead to many simply stopping such prescribing, which would result in limiting treatment access for chronic pain patients. Plus, he said education requirements won’t stop those “bad apple practitioners…but it will be a hardship on other physicians who’ve most likely been prescribing appropriately.”
“(Mandatory education) is like trying to use a blunt instrument to fix a really complex problem,” Stream said. “Our academy’s position is that we can police ourselves…what we need are the tools to do it.”
One of those tools are state-based electronic prescription drug monitoring registries, which allow physicians see a patient’s prescription history in effort to prevent “doctor shopping,” a tactic some people use to get multiple painkiller prescriptions. Stream uses such a registry in Washington and said it’s been helpful in determining if a patient is inappropriately getting multiple prescriptions.
Right now, 38 states have active prescription drug monitoring registries, said David Kloth, a pain physician in Connecticut and a member of the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP). The problem is that not all the registries are doctor-friendly and there’s no interchange between states. For example, he said his office is a one- to two-hour drive from five other states, so it’s impossible for him to know if some of his patients are indeed doctor shopping. He noted that while federal lawmakers passed the National All Schedules Prescription Electronic Reporting Act in 2005 and authorized $55 million in funds to help states set up the registries, only about $4 million has been appropriated to states.
“In order to get physicians to be part of the solution, we need the tools,” Kloth told me. “But you have to work with physicians…we really do have the answers.”
Unlike AAFP, the AAIPP does support mandatory education for physicians who prescribe opioids, said Kloth, who added that there just isn’t enough support to get lawmakers to enact such a requirement. (One of the biggest objectors to such mandatory education is the American Medical Association, Kloth noted.)
Back in Utah, Webster, who’s also president-elect of the American Academy of Pain Medicine, said his state’s experience demonstrates that “physicians and education can have a large impact without the imposition of regulations that can have unintended consequences.” For example, part of the physician education component of Utah’s Use Only As Directed campaign focused on methadone, which is related to one-third of unintentional overdose deaths, yet only accounts for about 5 percent of opioids prescribed for pain. Webster said patients are often prescribed too high a methadone dose, doses are increased too rapidly, or a physician uses poorly developed analgesic conversion tables when switching a patient from one opioid to another. (In fact, Webster said if physicians would stop using such conversion tables, which don’t accurately account for the individual and diverse ways our bodies receive opioids, he predicts we could reduce opioid-related deaths by 15 to 20 percent.)
Webster said AAPM will soon offer a four-and-a-half hour online education course for physicians based on the Utah experience. He said the goal is to make such education practical, easy to access and easy to fit into physicians’ schedules.
At the end of the day, Webster said “we can probably reduce (opioid-related deaths) by 30 percent just with physician education.” He noted that improving patient safety in the clinical setting will hopefully have a positive trick-down effect on diversion and illicit opioid use.
“We can address our patients, but we have very little influence on the larger group of people,” he said. “People have to understand that these drugs can kill and we need them to be engaged in solving the problem if we’re to solve the larger, global problem of prescription drug abuse.”
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for the last decade.