Help on avoiding opioid prescribing pitfalls

When doctors prescribe painkillers, some of them say their concerns aren’t strictly clinical.

In recent years, physicians, particularly those who specialize in pain treatment, say they have been under increased scrutiny by law enforcement agencies and regulators. At the lead is the U.S. Drug Enforcement Administration in its efforts to fight prescription drug diversion.

Investigations and prosecutions of doctors for improperly prescribing opioids have some physicians looking over their shoulders as they treat patients for chronic pain. In 2006, the DEA offered guidance about what practices may indicate inappropriate prescribing, but the action didn’t eliminate all physician apprehension. Doctors still find themselves teetering on a tricky ledge of responsibility, juggling their duties of addressing the pain of their patients while trying to prevent misuse of prescription drugs.

The crisis of opioid overdoses is real, and the numbers associated with it are striking. In 2008, opioid prescription painkillers played a role in 14,800 drug overdose deaths in the United States, according to a study in the Nov. 4, 2012, Morbidity and Mortality Weekly Report from the Centers for Disease Control and Prevention. Consider that in 1999, the total of those deaths — 4,000 — was closer to a quarter of that number. In addition to these fatal overdoses, opioids lead to more than 340,000 emergency department visits annually, the CDC says.

Pain medicine organizations have worked to educate doctors about how to prescribe opioids safely and minimize the likelihood of abuse of the drugs. At the same time, the AMA has taken steps to combat prescription drug abuse and diversion while teaching doctors about the effective use of opioids. In 2005, for example, the AMA joined other organizations to support passage of the National All Schedules Prescription Electronic Reporting Act, which funds the creation of state prescription drug monitoring programs.

At its Interim Meeting in November 2012, the AMA House of Delegates directed the Association to promote doctor training and competent use of controlled substances and encourage use of certain screening tools to identify patients at risk of abusing prescription drugs. During the meeting, R. Gil Kerlikowske, director of the White House Office of National Drug Control Policy, headed an educational session on prescription drug abuse and outlined President Obama’s plan to reduce misuse of such drugs and related overdose deaths.

Physician education is a key component of the AMA’s approach to fight opioid abuse and ensure appropriate pain management of patients. In 2004, the AMA developed a free, 12-hour continuing medical education program on pain management. More than 155,000 CME certificates were issued through the online version.

More recently, the AMA has launched a series of 12 webinars, free to all physicians, on topics related to responsible opioid prescribing. The CME program, part of the collaborative for the Prescribers’ Clinical Support System for Opioid Therapies, is certified for AMA PRA Category 1 Credit. Webinars are archived for viewing at any time.

The first webinar was unveiled in November 2012 and details eight principles to manage pain and reduce harm when prescribing opioids. The principles include: assessing a patient’s history of substance abuse to determine the risk for abuse; avoiding use of benzodiazepines with opioids; and reducing the opioid dose if a patient develops respiratory problems.

In his presentation, Lynn R. Webster, MD, president-elect of the American Academy of Pain Medicine, discusses how physicians can identify patients who are appropriate for opioid therapy. The webinar also examines how to monitor and evaluate a patient’s response to treatment.

In the second webinar, which went online in December 2012, CDC officials explain prescription opioid overdoses and the public health response. The session gives an overview of the epidemiology of prescription drug overdoses and deaths, and reviews practice strategies to promote proper prescribing.

With other webinars still to come, physicians can use such education effectively to evaluate and manage the legitimate needs of approximately 116 million Americans with chronic pain. An 2012 Institute of Medicine report said many pain patients don’t get adequate treatment, and it called for better training of health professionals on prevention and management of pain.

These patients deserve the most effective treatments available. If there is any prescribing hesitancy, they may be denied optimal care. At the same time, unchecked opioid abuse can have fatal consequences. The AMA webinars take both factors into the opioid equation to provide a solution that lets physicians prescribe with confidence.