Hard to kick
Local doctors walk fine line when prescribing opioid painkillers
Confirmation last month that music icon Prince died from an accidental overdose of an opioid medicine hammered home what statistics have shown for years: Painkillers can be actual killers.
Opioids (also called opiates)—compounds either naturally or synthetically derived from opium—have various names and come in various strengths. Prince’s autopsy found fentanyl, which is about 50 times more powerful than heroin and, according to The New York Times, attributed by federal officials to OD incidents “occurring at an alarming rate throughout the United States.” Related narcotics commonly prescribed include tramadol, codeine, hydrocodone (in Vicodin/Norco), oxycodone (in Percocet/Oxycontin) and morphine.
The death toll is climbing, up to around 15,000 Americans a year. The medical community has taken notice and established stricter prescribing guidelines. The effect has been fewer prescriptions since 2012 (down 12 percent or 18 percent, depending on the health-data reporter) but not a corresponding downturn in fatalities.
Meanwhile, two new studies—one on animals, one on human patients with sickle-cell anemia—have found that opioids actually may make pain worse with long-term use. The first study found a negative physiological reaction in the nervous system of rats; in the second, patients reported worse symptoms.
Since so many patients have been prescribed opioids for so long, often in escalating doses, the new evidence that’s mounting places health care at a crossroads.
Dr. Brandon Stark is a Chico physician certified in family medicine and trained in addiction treatment, and Dr. Mark Lundberg, Butte County’s outgoing public health official, just this week joined the addiction treatment team at Butte County Behavioral Health. Both stress that opioids are valuable when prescribed and used appropriately, but they see the way medical protocols are evolving as signposts of change.
“For the last decade or so, doctors trying to be good doctors and reduce suffering prescribed a lot more pain-relievers,” Stark said on Thursday (June 30). “I don’t think anyone was trying to do the wrong thing … well-intentioned, but certainly we didn’t know well enough the dark side of pain control.
“So now we’re at where we’re at, which is a huge epidemic of overdose deaths.”
To stem the tide, physicians have placed an emphasis on “judicious” prescribing, Lundberg said. Overdose statistics have stayed static, Stark added, because so many people were already dependent on the drugs before doctors started cutting back on prescriptions.
“We will see a decrease [in adverse effects],” Stark said. “It just hasn’t caught up yet.”
Indeed, physicians see two streams of patients: those already taking opioids and those now seeking pain relief.
“It’s certainly a challenge for those patients who are good patients, following a prescription by their doctor, but now they have tolerance and their body has adapted to these opiates,” Lundberg said by phone. “There’s the challenge of just getting them off the opiates now. That’s what we want to avoid to begin with … you’ve got to start on the front end.”
All Californians fall under the same rules requiring more safeguards to curtail opioid abuse. For example, effective July 1, every licensed prescriber and dispenser (i.e., doctor and pharmacist) must register to access the CURES database monitoring controlled-substance pharmaceuticals. This enables a physician to cross-reference a patient’s prescriptions to ensure he/she doesn’t have any undisclosed painkiller scripts.
Some of the strictures, including methods for prescribing and bans on refills, have led to restrictions at local practices and clinics.
“We have to make sure we have places for these good patients to go,” Lundberg said. “All [medical offices] have policies where they’re trying to be careful about how they prescribe opioids, and [in the short-term] they work great, but there could be some patients who get lost in this scrutiny of opioids.”
Stark says about 40 percent of his practice consists of addiction medicine versus family medicine, and that segment has grown steadily in the five years he’s been at Argyll Medical Group. Between 20 percent and 30 percent of his patients are dependent on opioids; that figure has stayed constant, but he says he sees only a demographic slice of the population because his office does not accept Medi-Cal.
The big picture is shocking. So are the individual stories, such as the demise of Prince, a devout Jehovah’s Witness who publicly eschewed drugs and reportedly didn’t drink alcohol other than red wine in moderation. The publicly released autopsy listed only fentanyl, no other causes or toxicology reporting.
Even with questions unanswered, Prince’s death should serve as a warning.
“Most of the overdoses, I think, are people who are on chronic medications and using them appropriately,” Stark said. “They just have been given a combination of pain relievers and sedatives; it’s been very common in the past, but that’s a deadly combination … and it also can be you’re taking your pain medicines appropriately and drinking beer on the weekend, or other sedatives we [doctors] haven’t always thought about in the past and have to be aware of.”
Stark included cannabis—not as a sedative, but as a substance a patient might use in conjunction with an opioid and potentially lose track of dosing.
“We don’t really know all these different ways you can get into trouble by taking your medicines appropriately but still get into serious health problems,” he said.
Lundberg emphasized the value of opioids in the medical toolbox, citing patients suffering from terminal illnesses and those fresh out of surgery as prime beneficiaries. He does not gloss over risks—after all, his new job focuses on substance abuse—but puts them in perspective.
“In their proper use, they are very important,” Lundberg said of opioids. “I hope that people don’t undermedicate when there are appropriate uses for these medicines.”