To combat the opioid crisis, let's start by empowering primary care to prescribe

A recent study found that 40% of primary care physicians refused new patients requiring opioid treatment. That’s a major problem for patients.

Opioids should always be a last resort. From massage and exercise to physical therapy to drugs like ibuprofen and acetaminophen, there are plenty of ways to manage pain without resorting to high-risk medications like opioids.

And yet, sometimes the benefits of opioid analgesics outweigh the risks.

It is essential to understand that even drugs such as ibuprofen and acetaminophen, although available over the counter, are associated with significant risks. Discussing these options with a healthcare professional is vital.

That is why that Michigan study—which found that 2 in 5 primary care practices rejected new patients requiring opioids—is so striking. Primary care doctors should rightfully be wary of any opioid treatment for pain patients. But they are also the best suited to treat such patients effectively. Not only do they understand their patients more than a pain management physician does, but they also have incentives to keep their patients functioning and healthy over the long term—incentives that even the most well-meaning pain management physician will never have. And, if a patient can't find a primary physician to responsibly monitor and taper their opioids, they are often forced to choose between living in severe pain or resorting to riskier street drugs.

Thus, doctors are stuck between managing opioid patients (which may be best for the patient, but entails enormous compliance obligations and possible investigations) or not prescribing at all (which avoids the direct risks and agony of legal drama). As time goes on, more and more PCPs seem to be opting for the latter.

A few months ago, a pain management physician friend told me a story about an 84-year old woman on Vicodin. The patient required one pill a week--half a pill before church, and another half for getting groceries. The rest of the week, she stayed at home and never touched the medication. Still, her primary care physician was terrified of opioid regulations and refused to prescribe Vicodin. So she sent the woman to the pain doctor for her weekly Vicodin.

The absurdity of the situation wasn’t lost on my friend. He knew that the woman’s primary care physician would be able to manage her Vicodin just as well as he could, if not better. “It’s all just silly,” he told me. “If anything, the whole situation just makes it harder to monitor and keep this woman safe.”

In my decade as a practicing physician, stories like this became increasingly common. So why are so many physicians so hesitant to prescribe opioids?

How we got here

In 1995, Purdue Pharma developed the prescription painkiller OxyContin. Purdue marketed the drug as a less addictive painkiller and began using heavy-handed marketing to push the product to doctors around the country. Around the same time, health thought leaders began to refer to pain as the “5th vital sign.”

Purdue's marketing suggested that Oxycontin had less side effects than traditional painkillers. This was false.

Hospitals began to penalize doctors and nurses whose patients had high subjective pain scores, and patients were encouraged to verbalize their pain with posters in the room with visuals of faces representing the level of pain.  Residents and fellows started their career with the understanding that pain is as important as heart rate, temperature, pulse oximetry results, and blood pressure.  That is to say, pain was seen as a life or death situation. Many doctors began to heavily prescribe OxyContin and other prescription opioids, and painkiller use (and addiction) began to soar.  

Around the turn of the century, regulators realized how destructive opioid overdose had become and began to crack down. State officials began mandating programs like Prescription Drug Monitoring Programs (PDMPs) to stem doctor shopping, while the DEA began to track down so-called “pill mill” practices. In this process, legitimate practices who were not operating a drug ring began to fear for their licenses. Some began to heavily taper opioid patients, leaving addicted patients looking for a fix. Others took more drastic measures to eliminate opioid prescribing altogether.

This graph from the CDC shows the rise of prescription opioids, heroin, and other opioids like fentanyl

This culminated in 2010, when prescription pill overdoses began to flatline while heroin deaths began to soar. A study published in 2014 found that, while opioid use in the 1960s almost exclusively began with heroin, 75% of heroin users in recent years began with prescription opioids. Another study indicates that 100 percent of children under the age of 18 with drug addiction started with a prescription drug. That is to say that opioid prescription fueled the epidemic, and when opioids became more difficult to obtain (and more expensive), individuals began turning to riskier drugs on the street.

As the opioid epidemic continued to explode over the last decade, regulators have continued to crack down on prescribers and pharmacists who were distributing prescription painkillers, paying close attention to the outliers in each group. Prescribers heard anecdotes about doctors getting in trouble—like Brian Koon, who successfully sued his doctor for $17.6 million for overprescribing opioids—and with every story or DEA bust, doctors became more and more hesitant to manage the complexities of controlled substance prescribing.

Instead, prescribers began increasingly tapering patients or sending them to pain management physicians. All the while, non-prescription overdose deaths continued to soar. In 2020, over 90,000 people died of drug overdose—mostly from non-prescription drugs like fentanyl. Reluctant doctors may have stemmed OxyContin use, but in doing so they may very well have accelerated the opioid epidemic.  

This chart is from the CDC's Vital Statistics Gallery, showing a whopping 93,331 predicted deaths in 2020. Click the image to learn more.

So, what can we do?

Empowering responsible providers to prescribe safe and effective pain medications is an essential step to keep patients experiencing moderate to chronic pain from suboptimal outcomes or resorting to dangerous street drugs. Even if they aren’t at risk of addiction, many patients simply need pain medication, and refusing opioids to such patients can have disastrous effects on their physical and mental wellbeing.

We need to bring back the balance and treat patients according to their needs based on diagnostic studies, physical examination, and the provider’s input. Importantly, we need to put this power back in the hands of primary care physicians who know their patients better than anyone. For these providers, careful prescribing can help patients tremendously, but fearful prescribing never will.

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Physicians can begin by listening to patients in pain intently, understanding where their pain comes from, and re-assuring them that their pain is real. Physicians should also go through the careful work of correlating the findings of physical exams with diagnostic studies and carefully weighing the risks and benefits of their pain management options.

Doctors are certainly overworked, and the extra time and care that controlled substances require may make accepting new opioid patients unfeasible. That’s okay. But when they can, primary care providers should own their position as perhaps the safest source of painkillers for potential patients, and they should work with patients to find them the care and support they need.

For current patients requiring opioids, physicians can work to create unique treatment plans that don’t arbitrarily taper or limit opioid prescriptions. The VADoD has some great resources on responsible opioid prescribing, as does this report from West Virginia. These guidelines may be lengthy and scattered--but once they’re integrated into the prescriber’s workflow--they can be powerful tools to stay compliant and better protect patients.

Similarly, health practice executives should do away with policies that arbitrarily limit opioid prescriptions or require strict tapering regimens. Instead, leaders can focus on programs that promote safe and compliant opioid prescribing—like regular UDTs, pain contracts, and in-depth PDMP checks.  Again, this may appear complicated and convoluted, and initially it probably will be. But solidifying these workflows is essential to providing patients with optimal care, managing risk, and protecting providers’ reputations.

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Opioids are risky and difficult to prescribe. Primary care doctors are under plenty of stress, and their hesitance to prescribe opioids is completely reasonable. But by creating a fearful environment around opioid prescribing, we are pushing patients away from the safest path they have to responsible pain management.

Primary care physicians know the patient the best, understand their needs, and are best equipped for regular follow-ups. It’s time to give them the reins.

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