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Why Do Doctors Keep Prescribing Opioids to Known Addicts?

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Open pill bottle on top of prescription padFor those in the trenches of the substance abuse treatment industry, new research out of Johns Hopkins University Bloomberg School of Public Health really stings.

The massive study analyzed the pharmacy claims of 50 million patients, with all kinds of payers, who filled “two or more prescriptions for any opioid during any calendar year between 2006 and 2013 in 11 states of interest,” according to the abstract of the study, which was published in the journal Addiction.1

They then whittled the group down to those also on buprenorphine, which is a medicine that contains an opioid but is intended to help people with a substance use problem eventually get off opioids.

The disappointing findings: More than 40 percent of patients on the opioid maintenance therapy, buprenorphine, filled an opioid prescription painkiller during treatment. More than two-thirds filled an opioid prescription painkiller after treatment.

How does this happen?

“While it is sometimes appropriate for a patient to receive a prescription opioid during medication-assisted treatment — patients who are in acute pain from a major trauma or surgery may require short-term prescription opioids in addition to their medication-assisted treatment — the researchers say they are concerned to see such high rates of combined use of these products,” Johns Hopkins Bloomberg School of Public Health explained in a news release.

“This pattern suggests that many patients do not have well-coordinated treatment for opioid use disorders and chronic pain, which could lead to higher rates of relapse or overdose.”2

Lead Author Caleb Alexander said that this problem even exists shows that many people who set addiction-related policy in our country do not fully understand what addiction is. “Policymakers may believe that people treated for opioid addiction are cured, but people with substance use disorders have a lifelong vulnerability, even if they are not actively using,” he said. “Our findings highlight the importance of stable, ongoing care for these patients.”

So why do doctors keep prescribing opioids to known addicts?

Physicians Group Urges Family Doctors to Get Up-to-Date On Addiction

At the American College of Physicians Annual Internal Medicine Conference in San Diego in April, the organization put a strong emphasis on educating general practitioners about opioid addiction.

A freelance writer for Foundations Recovery Network attended the ACP convention this year as a member of the news media.

The organization issued a policy statement recommending that “physicians become familiar with and follow as appropriate clinical guidelines related to pain management and controlled substances such as prescription opioids as well as non-opioid drugs and non-drug interventions; the expansion of access to naloxone to opioid users, law enforcement and emergency medical personnel; the expansion of access to medication-assisted treatment of opioid use disorders; improved training in the treatment of substance use disorders including buprenorphine-based treatment; and the establishment of a national Prescription Drug Monitoring Program and improvement of existing monitoring programs.”3

In a presentation at the convention entitled “Evidence-based Tools for Screening Patients at Risk and Monitoring for Adherence,” Dr. Steven Stanos said a national monitoring program is urgently needed. He pointed out that when he practiced in Illinois, monitoring patients’ activities became difficult, since they could be in another state with a different policy, such as Wisconsin, Indiana or Iowa, within minutes.4

Not every state’s monitoring program — only Missouri doesn’t have one — communicates with the monitoring programs of other states.

Yet, as Stanos pointed out during his address, “You would be surprised what you would find on that list, correct?”

He said he recently had a patient come in and he quizzed her four different ways about what medications she was taking. She listed all her opiates, but never mentioned she also was taking benzodiazepines. Benzodiazepines and opioids mixed together can be a fatal mix. Stanos may have saved this woman’s life by checking the monitoring program.

“These programs are not doing any good if doctors don’t use them,” lead author of the Johns Hopkins study, Alexander, told NBC News. “We need to get to a point where checking a Prescription Drug Monitoring Program is just as routine as checking a patient’s kidney function before starting a high blood pressure medication.”5

Doctors Must Quiz Patients, Ask Probing Questions

According to the ACP, most people who need substance abuse treatment aren’t getting it. “Access to care for substance use disorders is limited,” the doctors’ group claims in its policy statement. “In 2014, 22.5 million people in the US needed treatment for an illicit drug or alcohol use problem, but only 18 percent received any treatment, far below treatment receipt rates for those with hypertension (77 percent) diabetes (73 percent) or major depression (71 percent).”

Stanos said properly prescribing an opioid and finding out whether your patient has a substance abuse problem really starts with a very simple question.

I say, “Tell me what you do from when you get up (to when you go to sleep), and walk me through the day,” the doctor explained. “You get a lot of information from that.”

He said the general practitioner should always find out what else is going on in their patients’ lives, beyond the particular ailment they schedule an appointment for. When doctors prescribe an opioid to patients with even the slightest risk of becoming addicted, it should require a treatment plan signed by both the patient and their doctor, confirming they are on the same page in terms of treatment goals, risks, etc. It’s also important that the patient understands refill policies and any consequences for violating those policies, Stanos said, and that should be in writing too.

Doctors always should ask probing questions, Stanos said, such as “Are you getting out and doing things with your family?”

Some patients may be in so much pain they don’t get out and about. It’s important to find out how they are spending their time. If a patient mentions they can’t make it to their child’s soccer games, ask, “Why can’t you go to your son’s soccer game? What’s the reason?” He also believes in regular urine testing of patients.

As for the Johns Hopkins study that showed people in treatment are still being prescribed opioids, study co-author Matthew Daubresse said in the news release, “Many patients, especially those with shorter lengths of treatment, appear to be continuing to use prescription opioids during and after buprenorphine treatment.

“We need to find better ways to keep patients engaged in long-term treatment, and these efforts couldn’t be more urgent given how many Americans continue to die or get injured from opioids.”


Sources

1. Daubresse, M. et al. (2017, June). “Non-buprenorphine opioid utilization among patients using buprenorphine.” Addiction. Retrieved May 7, 2017.
2. Many patients receive prescription opioids during medication-assisted treatment for opioid addiction. (2017, Feb. 23). Johns Hopkins Bloomberg School of Public Health. Retrieved May 7, 2017.
3. American College of Physicians. (2017, March 28). “ACP issues recommendations to prevent and treat substance use disorders.” Retrieved May 7, 2017.
4. Stanos, S. (28 March 2017). “Evidence-Based Tools for Screening Patients at risk and Monitoring for Adherence.” American College of Physicians Internal Medicine Meeting, San Diego.
5. Fox, M. (2017, Feb. 23). “Addicts get opioids during, after addiction treatment, study finds.” NBC News. Retrieved May 7, 2017.

Written by David Heitz

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