Enough painkillers were prescribed in 2010 to medicate every American adult around-the-clock for a month, according to the Centers for Disease Control (CDC). Although most of these pills were prescribed for medical purposes, many ended up in the hands of people who misused or abused them.
The CDC, the Office of National Drug Control Policy, the Drug Enforcement Administration, the Food and Drug Administration, and Congress have identified that we are in the midst of an epidemic of prescription drug misuse, dependence, and overdose, meaning that a disproportionately large number of individuals within communities across the US are being affected at the same time.
Additional statistics from the CDC confirm that deaths from prescription painkillers have reached epidemic levels in the past decade. Consider that the number of overdose deaths from these doctor-approved medications is now greater than deaths from heroin and cocaine overdoses combined. More deaths are caused by prescription overdoses than by motor vehicle accidents. Over 16,000 overdose deaths occurred in 2012.
A big part of the problem is the nonmedical use of prescription painkillers: when prescription drugs are used recreationally for the “high” they create. In 2010, in fact, about twelve million Americans age twelve or older reported nonmedical use of prescription painkillers in the previous year. The problem also involves patients in pain who take the drugs and whose lives get worse. In fact, most people who die from overdoses had legitimate prescriptions and accidentally took too much or combined the painkillers with sedatives, resulting in respiratory arrest.
Improving the Prescription Process
Improving the way prescription painkillers are authorized and prescribed to patients can reduce the number of people who misuse, abuse, or overdose on these drugs. It is estimated that over 100 million Americans suffer from chronic pain and many of these people become dependent and addicted to opioids, starting with prescriptions from well-meaning doctors.
As I lecture around the country on chronic pain and addiction, I am always asked these questions by professionals:
• Why do doctors prescribe so much medication?
• Why don’t doctors warn their patients about the long-term risks of opioids, including tolerance and physical dependence?
• Why do doctors keep prescribing, even when patients are showing signs of decreased function and/or addiction?
• What can I do if I encounter a patient in such a situation?
Stepping in for a Patient’s Protection
I regularly hear complaints about doctors prescribing medications to patients who are in substance abuse treatment programs, for example, “Mr. Jones was on twenty-four medications. What can we do about doctors who prescribe so many at once? I can’t call the doctor; I’m only a social worker/counselor/marriage and family therapist, and the doctor won’t listen to me.”
Treatment professionals are frustrated, feeling powerless to influence a pain management system that is based on prescribing habit-forming medications. And yet they have an important opportunity to collaborate with doctors on behalf of their patients.
It is unreasonable to believe that all doctors are unapproachable or uninterested in hearing from a treatment professional. Send a signed release from your patient ahead of time, authorizing you to contact the doctor, perhaps with a note asking if you might arrange a time to call. Many will be grateful to know that you are working with their patient. Offer yourself as a resource to the doctor, and ask about any concerns with the patient’s medication use; often he or she will acknowledge concerns about how to address them.
Anticipate that most prescribers want to do the right thing, but some find that giving in to a patient’s request for pain-relieving medication—and then hoping for the best—is easier than denying it and risking a conflict-ridden conversation. Then, if the patient expresses concerns about reactions to the drug, these physicians will simply change the dosage or prescribe a different medication without much consideration of other approaches.
If a doctor will not discuss a case with you or won’t call you back, what then? Determine if there is a way to reach him or her in any other way. Consider scheduling an appointment to visit the doctor’s office or clinic and get acquainted with the office management or other practitioners who could help facilitate a meeting. Or perhaps send a letter of explanation to someone who might be able to get it directly to the doctor.
In addition, talk with patients who are in these situations to determine their goals. If they want help stepping down from medications, suggest ways they can explain this to their doctors.
In this way, you’ll be teaching patients how to advocate for themselves. You can even offer to rehearse these conversations, with you playing the role of the physician.
Addiction counselors and therapists are in the perfect position to help doctors in these matters. They are already experienced in motivating patients who are ambivalent or fearful about change or advocating for their own health. These same skills can be used to motivate doctors to be mindful of how they prescribe opioid medications. Counselors may find that many doctors will be pleased to know that their patient is working with a treatment professional and will be willing to collaborate on the best overall care plan for that individual.
Are there drug-free alternatives to pain recovery? Yes, and discussing these with your patients will be very helpful as they consider discontinuing opioid medications.
Treatment professionals’ responsibilities include advising patients on how to assess whether these medications are helping or making the patient’s life worse. This is the appropriate time to also present alternatives to opioids. If a patient’s function is diminished, despite some minimal pain relief, the better course of treatment may be to wean down and eventually discontinue the medications under medical supervision and find other ways to manage the pain. There are a multitude of holistic mind-body-spirit techniques that can be extremely effective.
A counselor can help support a doctor’s interest in the safest care for a patient by promoting these drug-free treatment techniques that may include cognitive behavioral therapies, motivational interviewing, mindfulness practice, yoga, gentle stretching and exercise programs.
If medication-free treatment is determined to be the best course of care for a patient, he or she will need your support and encouragement through the drug withdrawal process; while the prescriber is likely to appreciate the support you will be providing to optimize the patient’s outcome.
Mel Pohl, MD, FASAM is board certified in Family Practice, certified by American Board of Addiction Medicine and Fellow of the American Society of Addiction Medicine. He is the Medical Director of Las Vegas Recovery Center. He is on the planning committee for ASAM’s “Common Threads, Pain and Addiction” Course and cochair of ASAM’s Pain and Addiction Workgroup. He is a nationally known speaker and co-authored Pain Recovery: How to Find Balance and Reduce Suffering from Chronic Pain; Pain Recovery for Families: How to Find Balance When Someone Else’s Chronic Pain Becomes Your Problem Too and A Day without Pain. His new book from Da Capo Books, The Pain Antidote -Stop Suffering from Chronic Pain, Avoid Addiction to Painkillers, and Reclaim Your Life will be out next spring.