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Doctors grapple with when to write prescriptions for pain

‘We are undoing a bad practice that we have had ingrained in us,’ says Dr. Martin Makary, a professor of surgery at Johns Hopkins University.

‘We are undoing a bad practice that we have had ingrained in us,’ says Dr. Martin Makary, a professor of surgery at Johns Hopkins University.

Hospitals, insurance companies and pharmacies have begun following stricter guidelines for prescribing opioids in the wake of a devastating epidemic, but doctors worry they could be relying too much on anecdotal evidence when it comes to finding ways to deal with patients’ pain.

Today’s doctors must overcome decades of being told opioids were a safe, non-addictive pain reliever and reevaluate established practices for post-procedure prescriptions.

“When we look back at people who struggle with opioid addiction, many of those started with a prescription and many of those started with a prescription they didn’t need,” said Dr. Martin Makary, a professor of surgery at Johns Hopkins University. “Now we’re starting to say, even though they meet criteria (to be prescribed an opioid), is it appropriate?”

Guidelines

Many Maryland hospitals, insurers and pharmacies have adopted the Centers for Disease Control and Prevention’s opioid guidelines suggesting current opioid prescriptions for chronic pain be tapered down and for prescriptions for patients new to the drug be limited to seven days.

Insurers such as CareFirst BlueCross BlueShield, Maryland’s largest insurer, maintain that the guidelines are just that, guidelines. They want doctors to be thinking about prescribing an opioid before they do it

“We treat every patient as individuals and do the best thing for each patient and we want doctors to think about what is the best thing for my patient,” Dr. Daniel Winn, CareFirst’s chief medical officer, said.

Doctors say they share the concerns of the CDC and those implementing the guidelines, but they worry that the guidelines are anecdotal, not evidence-based, and that they could ultimately keep doctors from helping patients.

These doctors are especially worried that the guidelines adopt a one-size-fits-all approach instead of tailoring their approach to different procedures.

“I think it’s much harder to get a consensus by procedure,” Makary said. “I think we’ve taken the easy road of just no one should prescribe x, y or z.”

Just as concerning is the idea that adopting the guidelines could encourage doctors to prescribe too few opioids for pain.

Doctors worry that patients could either be in more pain than necessary after a procedure or find themselves cut off from the drug suddenly and forced into withdrawal.

Insurers say they want to avoid that.

“The message (to providers) was not just simply we’re going to put limits in place, but there’s a recognition that there is a huge national problem here and insurance companies aren’t the solution, but we are part of the medical community and we want it to be a partnership with patients and prescribers,” said Brian Pinto, director of pharmacy policy at CareFirst.

Through their numbers, CareFirst said that since they implemented the guidelines, their opioid prescriptions through the first quarter of this year are down 16 percent.

Educating doctors

When prescription opioid pills first hit the market, drug makers marketed the drug as a non-addictive medicine for pain. At the same time, there was a push for doctors to do more to treat their patients for pain, especially pain that resulted from procedures.

“You have to remember, our education has exclusively been opioids are non-addictive and keep people comfortable and when prescribing pain management, people tend to under-prescribe and have people suffer in pain,” Makary said. “That is the baseline education that doctors have had. … We are undoing a bad practice that we have had ingrained in us, and these interventions don’t reach every doctor.”

Gary Pushkin, president of MedChi, the Maryland medical society, has created a task force to address the opioid issue, especially looking at training doctors to recognize when they are prescribing too much and setting up education programs for doctors.

They are also looking to develop screening tools so they know when a patient walks in whether they might need help.

“Medical schools now are just starting to teach this stuff, but the majority of us in practice have never been taught in this outside of the pain docs and the addiction specialists,” he said. “How do you teach an orthopedist, who’s got a busy practice and lots of patients, if John Smith is a potential pain problem before I do an elected procedure? What signs do I have to guide me to say, ‘Well, John Smith has an immobilized fracture, does he need narcotics at all?’”

Doctors need several things to really make a measurable improvement, Pushkin said.

First, they need real, evidence-based data. Too much of what is available and what has been informing decisions like the CDC guidelines has been anecdotal, he said.

“It’s kind of the wild wild West,” he said. “Everything we’re doing right now is based on anecdotal evidence.”

Getting that data will help doctors make better decisions, and it will also help inform another piece that doctors need for improvement: better education.

Some of that education will be about the appropriateness of opioids and opioid dosages. But it will also include a look at non-opioid alternatives to pain relief, including non-opioid pain medications and treatments like acupuncture and physical therapy.

Improvement will also come from new doctors who are thinking about this while they go through their medical education.

“The students have seen up close the consequences of the opioid epidemic,” Makary said. “I think students in general today are asking more about appropriateness of care, maybe more so than past generations.”


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