Editor’s Note: Jennifer Caudle is a board-certified family medicine physician and assistant professor of family medicine at the Rowan University School of Osteopathic Medicine in New Jersey. Follow her on Twitter @DrJenCaudle. The opinions expressed in this commentary are solely those of the author.
Jennifer Caudle: Prince's overdose reopens issue of opioid problem, in part spurred by overprescribing
Caudle: U.S. doctors need to take a step back and re-evaluate prescribing practice
It breaks my heart, as a family physician, to see patients struggle with addiction to prescription painkillers. As a medical student, I was taught that pain was the “fifth vital sign” – on hospital rounds with my team of fellow medical students, residents and senior physicians, we learned the importance of assessing and managing patients’ pain.
But somehow things have gotten out of hand. My profession is supposed to heal people, but when it comes to opioid abuse, it seems we are part of the problem.
In 2013 alone, health care providers wrote nearly a quarter of a billion opioid prescriptions – enough for every American adult to have “their own bottle of pills,” says the Centers for Disease Control and Prevention. Some of these very prescriptions caused harm. I can say this because we know at least half of all opioid overdose deaths involve a prescription opioid.
From 2000 to 2014, nearly 500,000 people died from drug overdoses. Even more staggering is that the number of opioid overdose deaths in America, if averaged over a year, would be 78 per day. The crisis cuts across all our society, and even the rich and famous are vulnerable.
Prince: The artist
We are discussing this again because of the news about how Prince died. The musical genius died of an accidental opioid overdose. The drug fentanyl is one of the strongest painkillers available. We don’t know yet where he got the fentanyl, but it is prescribed for pain caused by cancers, and also made illicitly and sold on the streets.
How have we come to this opioid dependent point in America?
Since 1999, the amount of prescription opioids sold in the United States has nearly quadrupled, but there hasn’t been a major change in the amount of pain that Americans report. The “amount” of pain is important because historically opioids have been reserved for those with moderate to severe pain resulting from circumstances such as surgery, injury/accident or cancer.
Every day I see patients who have been prescribed these medications – but not for these (or similar) medical reasons. So why are health care providers writing so many opioid prescriptions? Have we overestimated the pain scales we were taught as medical students? Are we caving to pressures placed on us by drug-seeking patients to prescribe these medications? Are we simply not paying attention?
To answer these questions – to solve this urgent problem – we need to stop overestimating our patient’s pain. We should be treating and assessing pain appropriately, in the way our medical training dictates.
We must be immune to pressures from patients who have been led on by the ubiquitous pharmaceutical ads in magazines, on the Internet and TV: Our first job as health care providers is to “do no harm.”
I have been yelled and cursed at (even walked out on) by patients who become angry with me because I would not prescribe opioids when not appropriate. We cannot ignore that up to 1 in 4 patients on opioid therapy struggles with opioid addiction. Not paying attention to this simply isn’t an option.
As an osteopathic family physician in an academic medical practice, my colleagues and I, like many other physicians, have taken a judicious approach to prescribing opioids.
My office has “controlled-substance agreements,” for example, that a patient receiving opioids or other controlled substances must sign. These contracts require, among other things, that patients get their medications from only one pharmacy (pharmacy-hopping is not allowed), take their meds only as prescribed, return to the office for refills (meds cannot be refilled over the phone) and be subject to random drug screening. In addition, we also use the national Prescription Drug Monitoring Program, which allows providers to see which controlled medications patients have been prescribed by others.
We also regularly attend lectures and training on how to prescribe opioids and other controlled substances properly.
In short, we take this seriously.
Thankfully, many providers throughout the country are using these resources regularly to curb the inappropriate prescribing of opioid medications as well.
To be sure, the issue of opioid abuse and overdose is a complex, multifaceted issue, and the prescribing of opioids is just one aspect of this problem. Many doctors are prescribing these medications appropriately and many patients are taking these medications the right way. In fact, I often remind patients that opioid prescription medications are not bad – they are quite useful in treating pain when used and prescribed appropriately.
And as a physician, my intention here is not to place the blame of opioid overdoses solely on health care providers. Rather, it’s a wake-up call for us to take a step back and re-evaluate our prescribing practices. Not only is this appropriate, but it’s simply “good medicine.”
Jennifer Caudle is a board-certified family medicine physician and assistant professor of family medicine at the Rowan University School of Osteopathic Medicine in New Jersey. Follow her on Twitter @DrJenCaudle. The opinions expressed in this commentary are solely those of the author.