Physicians urged to detect prescription drug abuse

Medical leaders say physicians and medical students need more training to spot and treat prescription drug abuse. With the proper training, they say, doctors would be better suited to help reduce the high number of abusers of controlled prescription drugs.

They are urging greater education in response to a new national report that found 15.1 million Americans abused controlled prescription drugs in 2003 -- nearly double the 7.8 million in 1992. More people abused these drugs than the combined number of abusers for cocaine, hallucinogens, inhalants and heroin, according to the report by the National Center on Addiction and Substance Abuse (CASA) at Columbia University in New York.

The report indicates that many physicians are not trained to recognize and prevent patient abuse of controlled prescription drugs. Of 979 physicians surveyed in 2004, only 19% said they had received any medical school training in identifying prescription drug diversion. Just four in 10 doctors said they had been trained in medical school to identify prescription drug abuse and addiction.

"[Doctors] acknowledge that more training would be useful to them in these areas," said Susan Foster, who directed research for the report and is CASA's vice president and director for policy research and analysis.

CASA, a national organization that studies substance abuse, did a three-year study of prescription opioids, central nervous system depressants and CNS stimulants. From 1992 to 2003, written prescriptions for controlled drugs increased more than 150%, about 12 times the rate increase in population. The number of abusers ages 12 to 17 jumped 212%.

Health care practitioners routinely fail to recognize the signs and symptoms of substance abuse, and many are uninformed about the laws and regulations of administering controlled substances, the report said. More than 40% of physicians don't ask about prescription drug abuse when taking a patient's health history, and one-third don't regularly obtain patient records before prescribing controlled drugs.

The report noted that 47% of physicians said patients commonly try to pressure them into prescribing a controlled drug.

Some physician leaders, including those who specialize in pain treatment, agreed with many of the report's findings.

"We're failing our medical students and our medical doctors by not training them [about controlled prescription drug abuse and addiction]. There is a huge need for education," said Scott Fishman, MD, president of the American Academy of Pain Medicine and professor and chief of the division of pain medicine at the University of California, Davis.

The Assn. of American Medical Colleges said medical schools are required to provide education on pharmacology, but specific curricula decisions are left to individual schools.

Questionnaires found 86% of seniors graduating in 2002 said drug and alcohol abuse training was appropriate. That number climbed to 90% in 2004. Also, 53% of graduating seniors in 2004 said they had received appropriate education in pain management, up from 45% in 2002.

"These are things that schools are paying attention to," said AAMC Senior Associate Vice President for Medical Education M. Brownell Anderson.

Anderson said she was not sure why the AAMC questionnaires had differing opinions from the CASA report but said some respondents for the CASA report might have graduated from medical school before substance abuse education was emphasized as much as it is now.

Due diligence required

Responding to the CASA report, AMA Trustee Rebecca J. Patchin, MD, an anesthesiologist and pain-management specialist in Riverside, Calif., said the Health Insurance Portability and Accountability Act has made it tougher to get patient medical records. But she said doctors must be diligent to check for past or potential drug abuse. "[The report] points to the need for all of us to do a good history."

CASA recommends that groups such as the AAMC require education and training specifically in prescribing and administering controlled drugs and identifying diversion. It said the American Board of Medical Specialties should require such knowledge as part of its minimum standards of competency.

Practicing physicians also can take steps to improve how they prescribe and monitor controlled drugs.

B. Todd Sitzman, MD, MPH, director of the Center for Pain Medicine in Hattiesburg, Miss., said doctors might be reluctant to prescribe pain medications for fear of prosecution. But he said they can protect their practice by treating the source of the pain, checking a patient's history of substance abuse, documenting care and having periodic follow-ups.

Nunda, N.Y., family physician Norman Wetterau, MD, said doctors should carefully screen patients before prescribing controlled drugs.

"When a patient comes from another doctor, you should call the doctor up and see what's going on. The best thing for stopping drug abuse is using the telephone," said Dr. Wetterau, chair of the public health commission of the New York State Academy of Family Physicians.