October 27, 2013

Changes in opioid prescribing

How we use opioids has changed enormously over the last year.  We used to think, and be taught, that opioids had minimal risks and that patients should be given whatever they needed for pain relief..  This belief went so far that the Medical Board of California mandated that every physician get 12 hours of training in using opioids.  All of that changed in late 2012 when the Centers for Disease Control issued a study showing that as opioid sales went up, so did deaths from prescription opioid overdose, along with emergency room visits and entry into drug abuse treatment programs.  Couple that with the realization that high school students are using opioids obtained at school or from friends and then turning to drugs like heroin, so that we have a spike in heroin deaths amongst kids.  Clearly, the old mantra that the drugs were safe and no one would get addicted was wrong.  Good solid people with jobs and families and high school students were getting addicted and dying.

That realization creates a problem for doctors.  On the one hand, we want to treat pain.  On the other, the first dictum of medicine is, “First of all, do no harm.”  It is easier for a camel to go through the eye of a needle than to balance these conflicting points.

We are making several changes to how we approach the treatment of pain.  The first is what we focus on.  We used to focus on pain.  Now, the shift is to function.  This shift is appropriate:  if you can do the things you want to do, you really don’t care how much you hurt.  The FDA, correctly acknowledged this change by changing the indication for extended release opioids, like OxyContin, MSContin, Opana and Exalgo, from “moderate to severe pain” to “ER/LA opioids are indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.”  This language means that physicians will have to show that other treatment options, such as anti-inflammatory medications and physical therapy or cognitive behavioral therapy or injections have not worked satisfactorily.  Also implicit here is that we are not looking only at pain ratings but also function.

Another recent change is the DEA’s decision to reclassify hydrocodone from a Schedule III to a Schedule II drug.  This means that providers will no longer be able to call in Vicodin:  the patient will have to bring in a written prescription, just as you have to for Percocet.  This move is a good one.  For example, hydrocodone drugs are often prescribed by dentists.  But the effectiveness of hydrocodone was proven by showing that they were as good, not better than, ibuprofen.  So, why use hydrocodone routinely when ibuprofen is just as good and much safer.  Also, I see many patients who have been started on hydrocodone from other doctors.  I would prefer to see these patients before they are given opioids, so we can see if we can keep them off of them.

So, there has been a major change in how opioids are being prescribed.  At the same time, there are some groups, such as PROP, who want even stricter controls.  They argue for a 90 day limit on prescribing and a 100 mg of morphine equivalent dose as the upper limit.  Speaking as someone who only treats patients with chronic pain, PROP’s stand is too conservative.  There are patients who need more than a 90 day course of treatment.  And the 100 mg limit is arbitrary and impossible to define.

We are left with a new center point as to how we treat chronic pain with opioids.  The bottom line is that we continue to be committed to providing what is best for our patients.