Opioid Fight

An April 15 article in the Democrat-Gazette took aim at doctors for the opioid epidemic. The blame game makes for great headlines, particularly during a crisis.

According to the Centers for Disease Control, over 100 people die every day in America due to an overdose of opioid drugs. Prescription medications account for 40 percent of those deaths. The truth is there is more than enough blame to go around. Rather than attacking doctors, let’s look at what doctors have done right.

Nationally, from 2013 to 2017, the number of opioid prescriptions written by physicians and other prescribers decreased by 22 percent, according to IQVIA, a national data analysis company. Prescribing of pain medications has declined in every state, including Arkansas (12.8 percent). That reduction didn’t happen by accident, and it didn’t happen overnight.

Physicians, like everyone else, were caught off guard at the magnitude of the opioid abuse epidemic – see July 2018 Journal Commentary (added here after publication). However, long before there were headlines, Arkansas physicians began working to address this crisis in our home state.

In 2011, physicians helped pass legislation to create Arkansas’ prescription drug monitoring program (PDMP). The PDMP is a database of controlled substances prescribed and dispensed to patients. Physicians and other clinicians are able to access the PDMP to see what medications their patients are taking, and with this information help avoid drug interactions, prevent “doctor shopping” for narcotics, and identify their patients who might need help for addiction or abuse.

Arkansas was one of the first states to develop opioid prescribing guidelines for emergency rooms. Physicians, working with the Arkansas Department of Health and other organizations, created the guidelines to help reduce prescribing of opioid pain medications in hospital emergency departments. In 2015, the Arkansas Medical Society (AMS) drafted legislation to require every hospital in the state to adopt these or similar guidelines.

The legislation became Act 1208 and included other tools to address the opioid crisis. These include allowing the PDMP to alert a physician if their patient is getting opioids from other prescribers; allowing the PDMP to report prescribers to their licensing board if it appears they are prescribing or dispensing in an unsafe manner; mandatory PDMP use by prescribers who violate prescribing laws or regulations; mandatory prescribing education within the first two years of practice; requirements for treating patients with chronic pain; and provisions requiring all prescribers to adhere to standards that are at least as strict as those that apply to physicians.

More recently, Arkansas physicians supported legislation (Act 284 of 2017) that makes it easier for physicians and pharmacists to dispense naloxone to patients or caregivers without a prescription. Naloxone is the antidote used to prevent immediate death from overdosing. The AMS is currently supporting proposed regulations from the state Medical Board that more clearly define excessive prescribing, promote the use of alternative pain therapy, and ensure that when pain medications are prescribed they are done so based on sound medical judgment. The rules will limit initial prescriptions to seven days and set daily maximum dosages unless the physician clearly documents the reasons and justification for going beyond those limits.

On a national level, the AMS is one of eight state medical associations and 18 national medical associations that make up the American Medical Association Opioid Task Force. Formed in 2014, the mission of the task force is to identify best practices to combat opioid abuse and implement those practices into the day-to-day practice of medicine. The recommendations coming from the task force have included registration and use of prescription drug monitoring programs, greater access to naloxone, comprehensive care for patients in pain and with substance abuse disorders, and targeted education on opioid prescribing, pain management, and addiction treatment.

These recommendations along with a greater awareness of the opioid crisis have had positive results. In 2016, physicians accessed prescription monitoring program information over 136 million times, a 121 percent increase over 2014. Over 118,550 physicians have completed educational courses and nearly all 50 states have enacted improved naloxone access laws.

While there is more to be done, we also cannot forget that pain medications, like other prescription drugs, have a place in the care of patients with severe pain. Imagine having a total hip replacement or open-heart surgery and being told, “take two aspirin and call me in the morning.”

We must be careful to craft responses to the opioid crisis that do not make matters worse by driving patients to illegal drugs like heroin. We should not make criminals out of patients who have become addicted to pain medication. We should help them. The physician’s creed, “first, do no harm,” must be our guide.