It All Starts with Physician Education: Opioids and the Current State of Pain Management

Steve Gelfand, MD, FACP

Secretary of Physicians for Responsible Opioid Prescribing (PROP)

Steve Gelfand, MD, Secretary of Physicians for Responsible Opioid Prescribing (PROP; www.supportprop.org), discusses the risks and benefits of opioids for chronic noncancer pain.

Do you agree with the characterization that there is a crisis or an epidemic of opioid abuse and misuse in this country?

Yes, I agree. I think we do have an epidemic. I think we have a public health crisis in regard to prescription opioids. The CDC recently estimated about 15,000 people a year die from prescription opioids. That could actually be an underestimate because the figures coming out of the Office of the Florida Medical Examiners, which is probably the most complete data in the nation, have found the number of opioid related deaths in 2010 was over 6,000 in that state alone. It’s true that Florida has the highest oxycodone prescription rate, probably due to all the pill mills down there, so the data may be a little bit skewed. But, still, from one state alone, we see over 6,000 opioid-related deaths. That’s all prescription opioids, too; oxycodone was number 1 and I think methadone was number 2. And many of the people who are addicted to these medications and dependent upon them started getting prescriptions from their doctor for some type of pain. It’s a major problem.

What are the chief causes of this? You mentioned pill mills, but there has also been an increase in legitimately prescribed medications. Who is prescribing all these pills?

I think it starts with primary care doctors, who have been taught over the last 10 years that pain is undertreated and that opioids are underused, with no scientific evidence behind those claims. This was started by people from the industry, pain management doctors, and organizations like the Pain Policy Group at the University of Wisconsin. They got together in the late 1990s and started a campaign to greatly expand the use of opioids around the same time that OxyContin was approved. Primary care doctors got the idea that opioids are supposedly safe and effective for chronic non-cancer pain, so now they prescribe them inappropriately for all types of chronic pain.

"Primary care doctors got the idea that opioids are supposedly safe and effective for chronic non-cancer pain, so now they prescribe them inappropriately for all types of chronic pain."

There has been an effort to make physicians, especially primary care physicians, more aware of the risk/benefit ratio of these drugs, yet the number of prescriptions continues to rise. What’s the reason for that?

There is still a deficiency of education in primary care. An FDA advisory committee in July 2010 strongly recommended that physician education in regard to the use of opioids needed to vastly improve (http://bit.ly/KHlvdq). The committee made a very specific recommendation to undertake educational efforts that were not influenced by industry. PROP has addressed this problem by trying to provide educational resources for primary care doctors in particular, spelling out the myths and facts surrounding opioids and chronic pain. We published a brochure titled Cautious, Evidence-based Opioid Prescribing (http://bit.ly/LRD6FK) that addresses these issues.

These drugs carry risks, particularly in regard to treating patients with chronic noncancer pain who have significant mental health and substance abuse issues. Those are patients who really get into trouble with opioids. I see both sides of this issue in rheumatology in regard to who will and who will not respond well to opioids. I see patients who have chronic non-cancer pain that is not related to a tissue source but comes from a central nervous system etiology, such as people with fibromyalgia, who shouldn’t be on opioids. In fact, you published an article in February (http://bit.ly/M890JL) that looked at a study published in the American Journal of Medicine (http://bit.ly/KOJtbR) showing how many people with fibromyalgia are placed on opioids despite poor outcomes. On the other hand, patients with tissue-related chronic pain from osteoarthritis, particularly end-stage osteoarthritis, may respond to longterm opioid therapy. But the primary care community has basically been given a green light to prescribe opioids to just about anybody with pain, and there have been very few guidelines to educate primary care doctors about when it’s safe to use them and when it’s not safe to use them. Unfortunately, the instances where it’s not safe to use opioids are far more numerous than the instances in which it is safe to use them. It’s a complex issue and we need a lot more education.

"The primary care community has basically been given a green light to prescribe opioids to just about anybody with pain, and there have been very few guidelines to educate primary care doctors about when it’s safe to use them and when it’s not safe to use them. Unfortunately, the instances where it’s not safe to use opioids are far more numerous than the instances in which it is safe to use them."

What is your opinion of federal efforts to address this issue, such as the push to develop a class-wide REMS program, and congressional proposals calling for mandatory additional training on responsible opioid prescribing?

More needs to be done, but they’re certainly a good start. I think mandatory physician education that is not promoted and influenced by the drug companies is essential. At PROP, we believe that the drug companies should have nothing to do with physician education in regard to opioids. That’s one of the reasons why we established PROP and started an educational website for physicians. We’re not saying opioids should be banned. We’re saying their use should be limited; drugs like oxycodone should be limited to treating severe pain.

Another challenge is the FDA, which has been very slow in doing anything to limit prescription opioids for chronic non-cancer pain. They have fought that tooth and nail for 10 years and placed no limitations on the prescribing of oxycodone and other Schedule II opioids. The CDC, which recently come out with major data in regard to this problem, is the only government agency that’s really on the right track. Unnecessary opioid prescribing and prescription opioid abuse and misuse is a major problem that is growing, and there doesn’t seem to be any let up in the amount of people that we’re seeing who are dependent, addicted, or at risk of dying from prescription opioids. We are going to need a multifaceted effort to turn this around.

Have you seen a change in physicians’ attitude toward treating chronic pain with opioids?

I have seen a change in attitude among certain doctors who are respected in their fields and who are leading clinicians. But the problem still exists among a large percentage of the primary care community. It’s a lot easier for them to prescribe an opioid to somebody who comes in complaining of chronic pain then to really look at the complex underlying reasons for this patient having chronic pain. It’s also an economic issue for many prescribers.

In my opinion, I think it’s going to get worse before it gets better unless we have a real national movement to address the problem. The media broadcast bits and pieces about this, and every few weeks they’ll come up with another good report, but there has not been much follow through. The recent segment on 60 Minutes (http://cbsn.ws/ KrEvmd), in which Dr. Nora Volkow spoke about addiction being a disease of the brain that may not be reversible, was good. It’s certainly a step in the right direction to get doctors to understand what the consequences are of inappropriate prescribing of these medications.

At this point, how much of the onus should be on individual physicians when it comes to looking hard at the available data and changing opioid prescribing habits?

It all eventually boils down to the individual doctor, particularly primary care doctors who are the first to write the script for an opioid. They’re going to have to take responsibility. I understand their dilemma, particularly amongst some of the younger ones. They’ve been conditioned for so many years that opioid therapy is safe and effective. How do many of these patients get into trouble with these drugs in the first place, how do they first come into contact with them? It comes down to primary care. That’s why we need a massive educational effort. The bottom line is that the doctor has to be knowledgeable and responsible for prescribing a drug, and they need the right kind of information.

What are some of the situations in which the benefits of opioid treatment outweigh the risks?

In my field of rheumatology, we see patients who have end-stage arthritis (basically a boneon- bone situation), particularly in osteoarthritis, which is the most common type of arthritis and one of the most common causes of chronic pain. Patients who have this “bone-on-bone” situation and are in constant pain—who have not responded to non-opioid therapy (nonopioid drugs, injections, physical therapy, etc) and who may not be a candidate for surgery— in those instances a trial of opioids would be indicated if the patient did not have a significant underlying mental health problem like depression, or if they didn’t have a prior history of substance abuse. When I was in practice, I had patients in that situation who did well on low doses of opioids. But they comprised a small percentage of patients, less than 10%.

There are other situations in which opioids may be helpful. For example, if other drugs are not working, opioids may be beneficial in people who have diabetic peripheral neuropathy. Opioids may be helpful for neuropathic pain related to shingles, in those instances in which the patient hasn’t responded to other types of drugs. But, this comprises a small minority of the patients with chronic non-cancer pain. The most worrisome aspect is that a large percentage of patients with chronic non-cancer pain also have comorbid mental health issues, like depression and anxiety. They are the ones who are at risk with opioids, particularly in regard to developing dependency and addiction.

Is monitoring and ongoing risk assessment the key in patients in whom these drugs are indicated?

Definitely. The pain management industry is coming around to looking more closely at the risks. What they’re concerned with right now is monitoring patients after opioid treatment has already started. However, by the time you pick up on potential problems, the patient may be already addicted. The disease of addiction is one of the most difficult diseases in medicine to treat. It’s important to monitor these patients, but what I’ve always promoted is that we must be very selective initially in using these drugs. In other words, one way to prevent a patient from becoming addicted is by not prescribing an opioid that they may not need. It’s a very complex problem and that’s why I think we need to start with physician education.