Interview: Doctors Need Flexibility in Prescribing Opioids
By Sara Talpos
This shift had implications for both physicians and patients, wrote Kertesz, a physician in internal medicine and addiction medicine who holds positions at the University of Alabama at Birmingham’s Heersink School of Medicine and at the Birmingham VA Medical Center: “A relentless focus on physician prescribing” could incentivize doctors to quickly decrease or stop prescribing opioids to chronic pain patients who were previously stable and doing well. This could harm patients, he cautioned, without addressing the current causes of opioid-related deaths.
Since the release of his paper, which garnered wide attention among substance-abuse and addiction experts, Kertesz has continued to warn against overaggressive cutbacks in opioid prescribing. “People deserve individualized care,” said Kertesz in a recent Zoom interview. “Our health care system has been looking for a quick fix, both on the way up in this crisis, and on the way down. I pray for the day when we stop looking for quick fixes.”
This interview has been edited for length and clarity.
UD: There’s a narrative, you’ve written, of a chronic pain patient who starts on opioids and then becomes addicted very severely. If I understand correctly, this experience represents just a small number of chronic pain patients.
SK: There's a lot of debate about this right now because of changing definitions of addiction and how we measure it. But the popular cartoon of this situation was that somehow chronic pain patients have become all addicted to heroin and are all dying in the streets, and if we simply stop prescribing opioids to them, they'll be safer.
That was the popular conception. It was really reflected in a quote from Vermont's Governor Pete Shumlin in The New York Times, who said — and I'm paraphrasing: We didn't have this problem in this country until oxycodone started being handed out like candy. If we could just get together on this, we could solve this problem with a click of our fingers. The implication was, reduce the opioids [and] deaths will go down.
Everybody bought into that and managed to set aside any questions about the fate of the patients whose opioids were being reduced.
UD: You’ve said that a 2016 guideline from the Centers for Disease Control and Prevention took a sensible approach to prescribing opioids to chronic pain patients, by calling on physicians to weigh the harms and benefits of tapering a patient's opioid prescription. But you were critical of how that guideline was implemented. Can you elaborate?
SK: First of all, insurance payers, and health systems, and physicians all paid very close attention to a couple of numbers in that guideline that were given prominence. One concerned the dose of opioids that a patient might be on long-term. That guideline suggested that if a person was receiving a dose the equivalent of 90 milligrams of morphine a day — which is high — that might not be good. The way the guideline was written, it was pretty careful. It said, “physicians should either avoid going to such a high dose or very carefully justify it.”
But that subtlety of careful justification was not considered in any of the initiatives to implement the guideline. For example, the fraud investigators from the United States Department of Health and Human Services work hand in hand with the Department of Justice to find which doctors to investigate and prosecute. They paid attention to the number of patients receiving over 90 milligrams, and they routinely cited the guideline incorrectly, not referring to the idea that you could carefully justify such a decision.
Physicians who were seen as outliers in terms of the number of pain patients they served were subject to warnings, or investigation, or pressure — either from law enforcement, or from their medical board, or from insurers, or from malpractice lawyers who told them that they were at risk, or from their own employers.
UD: You wrote that in the year following the new CDC guidelines, some pain patients had their opioid prescriptions terminated. In the wake of this, some of those patients died by suicide, and some died in withdrawal. Some suffered medical decline or turned to illicit opioids. Yet no agency or insurer was systematically tracking these events. Why was there no push to collect that data?
SK: There was no political audience that cared. The people with long-term pain and disability who receive opioids are a highly stigmatized group. I would argue that being a person with pain who receives opioids may be, at this time, more stigmatized than having significant addiction problems.
There's certainly much more public advocacy and storytelling about the love we have for people with addiction who are dealing with recovery, compared to the storytelling in the popular media about people with pain who are on prescribed opioids.
When anyone institutes a policy change that affects a group with little political power and a high level of stigma, it's very easy to decide that there's no real utility in measuring what happens to them afterwards.
UD: What data do we have now that we did not have then?
SK: In the past five years, there have been over a dozen papers that attempt to retrospectively portray outcomes for patients whose prescription opioids are reduced or stopped. Generally, those papers fail to find any hint of a gain in safety or health benefit for those patients.
I say that carefully because many of us as clinicians have seen patients who are over-medicated, and we have seen patients where reducing a combination of sedating medicines helped bring them back to life. I'm not saying there's no one who benefits.
But in these large retrospective studies, the types of findings they show are increases in the rate of suicidal ideation [and] suicide death. In some papers, there's an increase in the rate of overdose death. In some, there's a deterioration of ongoing care for chronic medical conditions like diabetes and high blood pressure. If you can imagine somebody who has been going to primary care for chronic pain: When the doctor comes under pressure or decides they're going to make this change with the opioids because they have to, that can fragment the care relationship so that the patient doesn't stay in care for their diabetes and blood pressure issues.
I've also certainly been present for patients who exhibited suicidal behavior when their opioids were stopped. That, to me, signals a reason to think this is a very real concern. There's also a very long track record of risk factors for suicide, always including pain as one of them. If you take away the treatment for pain, that doesn't mean every person is going to have a suicidal event. In fact, it'll be a tiny minority, but you can see why the risk might go up.
UD: Often lost in all of this, you’ve written, is the helpfulness of medication-assisted therapy.
SK: Let's give credit that the federal government moved to liberalize the ability of physicians to prescribe one of the medications that has an evidence base for treatment of opioid-use disorder — that's buprenorphine. I am part of initiatives to expand addiction treatment, both in the Veterans Health Administration and outside of it, and I'm impressed that my fellow clinicians and the new crop of doctors and nurses and social workers take medication therapy for addiction seriously. But they haven't yet brought it to scale.
What troubles me is as we're pursuing addiction treatment with medication, we still haven't dealt with the fact that medication isn't enough for treatment of addiction in many cases. I'm not saying we should mandate social therapy. That's been proven not to be necessary, but a lot of people initiate treatment, and then they give it up because life sucks. We need to address the complexities of the lives of people who are recovering from addiction.
UD: Is there anything that you'd like to add?
SK: The Centers for Disease Control and Prevention clearly recognized that its 2016 guideline was misapplied, and they have attempted to correct course. Unfortunately, other agencies across society are unable to make a similar change, and physicians themselves have undergone a powerful culture change in which their attitude toward continuing or prescribing opioids in the outpatient environment is marked by fear and trepidation.
I speak to medical trainees and residents who tell me straight up: “Outside of the hospital, I'm afraid to start opioids ever.” They've all learned from this powerful narrative that the medical profession was partly guilty for a national tragedy, that we were betrayed by the pharma industry, and that there exists no such thing as a patient who has ever been helped by opioids outside of surgery or end-of-life care. There's truth to some aspects of what I just said, but it's really untrue to say that no patients ever benefit from opioids on an outpatient basis.
I would basically say, during the rise of opioid prescribing, the pharmaceutical industry taught us: “This is a simple problem. All we need to do is write more prescriptions and people will feel great.” Then, as we reduced prescribing, countless policy leaders and advocates and opioid litigation attorneys told us: “This is a simple problem. All we need to do is reduce prescribing while increasing addiction treatment.”
No one ever circled back to, how are we really going to take care of people who have disability, who have pain, who have complex medical illness, and who have been traumatized by our own health care system? The most typical thing I hear is, “Don't stop opioids suddenly,” as if that was all you needed to know.
I should add one more thing. There's a lot of litigation being settled right now between the manufacturers and distributors of opioid pain medications and the states, counties, Native American tribes, and cities that were done harm by what is said to be excessive distribution or sales. The distribution agreements that are reached very often include a measure to restrict the shipment and release of opioid pain medicines to pharmacies where the number of prescriptions is high.
I've heard from doctors who have been informed that any number of pharmacy chains will refuse to fill all of their prescriptions for opioids for all of their patients, no matter what happens to those patients. Here you have yet again a situation where the solution to a complex social dilemma has been written into litigation in such a way that individual patients will be lost in the shuffle and will be traumatized and will be harmed.
This article was originally published on Undark. Read the original article.
