Physicians struggle to treat pain amid opioid overdose crisis

The patients Richard Blondell, MD, treated in detox 10 years ago mostly were middle-aged heroin addicts with arms scarred by needle tracks. Today he sees patients in their early 20s who are hooked on something they can get legally: opioid pain medications.

"I don't see those hard-core drug addicts" much anymore, said Dr. Blondell, a family physician in Buffalo, N.Y., who specializes in addiction medicine. "It's all prescription pain drugs."

Addiction to pain medicine is occurring at alarming rates in communities across the country, and overdose deaths have more than tripled in a decade, according to a study by the Centers for Disease Control and Prevention.

In 2008, opioid prescription painkillers were involved in 14,800 drug overdose deaths in the United States, according to a CDC study published in the Nov. 4 Morbidity and Mortality Weekly Report. That was up from 4,000 such deaths in 1999.

The increase comes as national sales of opioid pain relievers to hospitals and elsewhere continue to climb. Sales rose from 1.8 kg per 10,000 people in 1999 to 7.1 kg per 10,000 people in 2010, the study shows.

Although the impact of opioid abuse is clear, the source of the problem is less so.

CDC Director Thomas Frieden, MD, MPH, faults a "few irresponsible physicians" for fueling the crisis. Pain experts, however, say the problem is more widespread. They say some well-meaning doctors are misinformed about the benefits and downsides of opioid pain relievers and thus overprescribe the drugs.

Because there is a shortage of pain specialists in the U.S., due in part to the relative newness of the specialty, the responsibility of managing pain increasingly is falling on primary care physicians, experts say.

"Doctors have caused an epidemic, not out of malicious intent but out of a desire to treat pain compassionately," said Andrew Kolodny, MD, a Brooklyn, N.Y., psychiatrist and president of Physicians for Responsible Opioid Prescribing, which aims to reduce morbidity and mortality from opioid prescribing. "We overprescribed and created a public health crisis."

Nationally, 4.8% of Americans 12 and older took prescription painkillers for nonmedical reasons in 2008-09, according to the MMWR study, which examined data from the 2008-09 National Surveys on Drug Use and Health. The extent of the problem varies widely by state, the CDC said.

In Oklahoma, where sales of painkillers are among the highest in the nation, 8.1% misused the drugs, the study shows. The smallest percentage of abuse was reported in Iowa and Nebraska, where 3.6% of residents took painkillers for nonmedical reasons. Iowa and Nebraska were among the states with the lowest sales of painkillers.

"The facts are truly devastating," said Gil Kerlikowske, director of the Office of National Drug Control Policy. The nation's painkiller crisis "is not a problem that will be solved overnight. But at the same time, we are clearly not powerless about this."

Preventing abuse

In addition to causing addiction and death, high doses of opioid painkillers can cause cardiovascular failure, fecal impaction, seizures and slowed or stopped breathing, according to pain experts. They recommend that physicians use opioid pain medications as a last resort for people with intractable pain who have failed safer alternatives. Such alternatives include cognitive behavioral therapy, physical exercise, yoga and nonopioid pain medications such as Tylenol.

Family physician S. Hughes Melton, MD, receives requests for opioid painkillers nearly every day at his Lebanon, Va., practice. Patient interest in the drugs has increased in the last decade. But even more concerning is the shift in the types of people asking for the medication.

Most requests in the past were made by older patients with chronic pain. Now, more healthy people in their 20s and early 30s ask for pain medicine.

"These are patients who want to experiment" with the drugs, he said.

In an effort to eliminate abuse of pain drugs, Dr. Melton thoroughly examines everyone who requests such drugs. He also reviews each patient's medical and prescription drug records, requests an x-ray to assess the source of pain and gives a urine drug screen to identify illegal substances.

Dr. Melton does not prescribe pain medication while awaiting the results of the urine screen and medical record checks.

"It's just our policy. And that relieves the pressure doctors often feel" from drug company representatives and patients to prescribe painkillers, he said.

Steven Crawford, MD, a family physician in Oklahoma City, takes similar steps to ensure that patient requests for opioids are legitimate. But verifying complaints of pain often is difficult.

For example, chronic pain, including back pain, headaches and limb pain, cannot always be seen during a physical exam or through imaging, he said. Another challenge is determining the severity of a patient's discomfort when deciding whether nonopioid medication could be used in place of more powerful medication.

Complicating matters are conflicting messages physicians hear about pain management. Though studies show that doctors sometimes prescribe opioid pain relievers inappropriately, an Institute of Medicine report in June found that chronic pain is undertreated.

The IOM said that for many of the 116 million U.S. adults with chronic pain, treatment is delayed, inaccessible or inadequate. The report called for greater training of health professionals on pain prevention and management.

"This is a very challenging and complex issue, and you can get caught in the middle of many people's addiction to this medicine," Dr. Crawford said.

Scaling back prescriptions

The message that pain expert Jane C. Ballantyne, MD, wants doctors to take away from the CDC study is that long-term opioid treatment does not work.

"It may provide comfort to people with refractory medical and psychiatric conditions, but it does not offer pain relief," said Dr. Ballantyne, a professor of anesthesiology and pain medicine at the University of Washington School of Medicine in Seattle.

She recommends that physicians consider prescribing opioid pain relievers for patients with acute pain or to ease a person's discomfort at the end of life.

For acute pain, the CDC encourages doctors to give a patient enough medication for three days rather than the more common practice of providing a 30-day supply.

Patients taking opioids should be monitored regularly for side effects, drug abuse and indications that the pain has decreased, experts say. When an individual's pain has lessened, physicians are encouraged to reassess the treatment plan and, if appropriate, gradually take the patient off the drugs.

Many primary care physicians admit that rejecting requests for opioid pain relievers can be difficult, in part, because patients often insist they need the medication.

Robert A. Lee, MD, a family physician in Johnston, Iowa, tells patients who are not candidates for opioid pain relievers that he will work with them to find ways to help them feel better. Like other physicians, Dr. Lee, president-elect of the Iowa Medical Society, said he offers compassion and empathy, along with treatment.

"My objective is not to leave you in pain."