By Harrison Jacobs
In the US, the number of deaths from drug overdoses exceeded the number of deaths from car crashes or guns in 2014, the most recent year for which data is available.
Legal prescription opioids like Oxycontin and Percocet, as well as illegal opioids like heroin, were involved in 60% of those deaths, according to a January report from the Centers for Disease Control and Prevention.
The overdoses have led the federal government to dub opioid abuse an epidemic.
The problem has gotten so bad that President Barack Obama recently allocated $1.1 billion to address the issue in his proposed budget for 2017. It follows up on a 2011 plan from the White House to address the issue through expanded education, enforcement, and drug tracking.
All of the attention on the opioid crisis has had a major unintended consequence, at least if you talk to many of the doctors who prescribe them: Many doctors are increasingly wary of prescribing opioids, according to several pain specialists we spoke with.
“Physicians are becoming hesitant to prescribing these drugs because of the bad publicity surrounding the abuse,” Dr. Ted Cicero, a professor of psychiatry at Washington University in St. Louis who studies opiate use, told Business Insider.
The making of the opioid epidemic
This development is just the latest turn in the decades-long saga that is modern pain management.
Opioid prescriptions have been skyrocketing since the early 1990s, when pharmaceutical companies introduced powerful new painkillers such as MS Contin and Oxycontin and medical groups began calling pain the “fifth vital sign” that doctors should attend to.
The increased acceptability and commonness of opioid treatment led to an explosion in prescriptions, as well as the development of “pill mills,” shady pain clinics whose sole purpose was to prescribe legal opioids without asking too many questions.
Before long, the US was flush with opioids; by 2011, 219 million opioid prescriptions were being handed out each year.
When the prescription-painkiller crisis became apparent, state, local, and federal law enforcement cracked down on prescribers and patients who used prescription opioids, according to Grant Smith, deputy director of national affairs at the Drug Policy Alliance, a nonprofit that advocates drug-law reform.
Many legitimate pain clinics were shut down along with the pill mills.
In recent years, the media and government focus on the opioid crisis has shifted to the explosion in heroin users. But some doctors say the crisis has also led to a major change in pain treatment.
“The pendulum in the 1990s was definitely swung all the way to the right with doctors prescribing opioids for everything. Now, the pendulum is swinging the other way,” Dr. Houman Danesh, the director of Integrative Pain Management at Mount Sinai Hospital, told Business Insider. “You have very few physicians that think opioids are appropriate for everything.”
Danesh said he prescribed opioids for no more than 5% of his pain patients — and almost always for a short duration of time. He instead relies primarily on physical therapy and interventional treatments such as spinal-cord stimulation, epidural injections, and steroid injections.
When Danesh began his career, he, like many specialists, relied more heavily on opioids as a treatment option. But he said witnessing the risks of opioids firsthand — combined with larger statistics brought to light by today’s epidemic — had forced him and many other specialists to question how appropriate opioids are as a pain treatment.
But while doctors may have “dropped the ball” by over-prescribing pain drugs, they shouldn’t swear opioids off entirely, according to Dr. Christopher Gharibo, the director of Chronic Pain Management at New York University’s Hospital for Joint Diseases.
“Medical care is not absolutes. There are many patients that benefit from these medications,” Gharibo told Business Insider.
A quickly changing medical discipline
While interventional procedures and physical therapy like those advocated by Danesh have long been part of the treatment oeuvre, many specialists relied on opioids because they were cheap and covered by healthcare when other options were not. The epidemic has sparked many doctors to advocate a more balanced approach that treats opioids as one option among many.
“We need to stop the reliance on medication,” Dr. Shalini Shah, the director of pediatric pain management at UC Irvine Health, told Business Insider. “This light on the opioid epidemic might be just what our specialty needed to be a bit more aggressive in finding new treatment options.”
A major change to the field has come not just in what doctors prescribe, but in how they evaluate pain itself.
In the past, doctors were focused on reducing or eliminating their patients’ pain as a benchmark of progress, constantly asking patients to rate their level of pain from one to 10. That encouraged doctors to use opioids, repeatedly upping the dosage to massive quantities to try to achieve that goal. Today specialists are focusing on increasing patients’ function, such as their ability to go to work or move physically, according to Dr. Neel Mehta, the medical director of pain management at Weill Cornell Medical College.
It’s a subtle change that nearly every doctor we spoke with indicated was crucial to reducing opioid overprescribing.
While the new paradigm among specialists is producing a big change in how pain is treated for new pain patients, there is still the problem of the existing use of prescription opioids by millions of pain patients. For some, the medications are life-changing, allowing them to return from chronic pain to something resembling a normal life. These patients, according to Mehta, often use moderate doses, in their prescribed manner, and have been successful with them for years.
Others, however, because of outdated prescribing practices, may be either addicted or “dosed into a hole,” as Gharibo called it, taking hundreds of milligrams of opioids a day to keep up with their pain and the potential of withdrawal.
Both situations present a major dilemma for pain specialists. Patients are often reluctant to get off the opioids, even if the doctor thinks they will benefit from doing so. At that point, it’s down to the specialist’s judgment about whether it is more ill-advised for the patient to stay on the opioids (which have a long list of long-term side effects) or to get off them (in some cases, opioids are the only safe route to pain relief, such as patients not healthy enough for surgery). For those patients addicted to opioids, reducing or eliminating the medication is a long, difficult route for both patient and doctor.
“There really is no free lunch out there for any treatment,” Gharibo said.
All this is to say that modern pain management is a major conundrum for pain specialists, with rarely an easy option for treatment. Primary-care doctors, who treat the vast majority of patients suffering chronic pain, have it even harder.
The biggest problem with treating pain
One of the greatest problems with the practice of pain management is how young the field is. Modern pain management has essentially been around for only about 30 years, with current opioid formulations around for even less time.
While many patients with chronic pain do use and benefit from opioids, there are no studies documenting their safety or effectiveness in long-term patients. The lack of literature regarding the long-term use of opioids may be partially to blame for the widespread overprescription of the drugs.
While pain specialists often stay abreast of the latest options for pain treatment, primary doctors — who prescribe most opioids in the US — hear about these advances later, if at all.
Most primary care doctors don’t have specific training in pain management. In medical school, students receive only a few hours at most of education on pain. For the average primary-care doctor who sees a new patient every 15 minutes or less, and has to address numerous medical problems in each visit, opioids emerge as a relatively cheap option, covered by healthcare and effective in the short term.
In many cases, primary-care doctors don’t fully understand the range of treatment options besides opioids.
“There is lack of education among treating physicians, nurse practitioners, and physicians that prescribe [opioids]. There’s a lack of understanding about what pain physicians can provide in alternative treatments,” Mehta said.
According to Mehta, the current situation is like if cardiologists never received referrals for pacemakers because primary-care physicians had never heard of the device.
For many patients in pain, primary-care doctors’ willingness to prescribe can be a lifesaver. While it would be ideal for every patient in need of pain management to see a pain specialist, the reality is that thereare only 3,000 to 4,000 pain specialists in the US, according to a 2011 report in Time. Most are grouped around major metropolitan areas. Many patients have no choice but to go to primary-care physicians to treat their pain.
As the prescription opioid and heroin crises have reached a fever pitch in the media, federal and state governments have responded with increased restrictions on opioid prescribing, prescription-drug-monitoring programs to track prescriptions, laws implicating doctors whose patients become addicted, and more detailed guidelines for prescribing. While these measures are, according to the pain specialists we spoke to, positive moves for bringing prescribing under control, the side effect is that primary-care doctors are more fearful than ever of prescribing the drugs. For many, the benefit isn’t worth the potential cost.
“I worry that patients are being hurt here,” Cicero said. “[Prescribing opioids] is a lot of paperwork, stress and anxiety for a general practitioner … We’re seeing physicians right now referring more and more patients to pain specialists. They don’t want to deal with it, and I don’t blame them.”
The paperwork isn’t the only issue. According to Shah, primary-care doctors are afraid of receiving sanctions from medical review boards that have become more strict in the wake of the epidemic.
“I see a lot of primary-care doctors who don’t want to prescribe these drugs and are handing them over to pain management because they are afraid of whatever sanctions may come,” Shah said.
Every pain specialist we spoke with agreed that the solution was for more doctor and patient education on pain-treatment options besides opioids, as well as for more diligent monitoring of those patients on the drugs for signs of addiction and effectiveness. But most conceded that adding required or even voluntary education for prescribing doctors will not happen without a fight.
And in a healthcare system that asks doctors to churn through patients to pay for the overhead, asking primary-care doctors to spend time monitoring patients in the detailed way that most pain specialists have done for years may be untenable.