JANUARY 12, 2017
The opioid dilemma puts pressure on every physician to pause and reflect. Physician anesthesiologists are dedicated to providing pain relief in the safest manner possible, which includes prescribing and managing opioid therapy when medical conditions warrant. What we face now is too many tragic instances of patients emerging from pain treatment regimens only to see their lives destroyed later through addiction.
Opioids include illegal heroin and prescription “pain killers” such as oxycodone, and the impact of these drugs is clear in Maryland and elsewhere. The numbers of opioid related deaths statewide increased 23 percent between 2014 and 2015, and have more than doubled since 2010, according to the latest Maryland health department report released this fall.
This month, the Centers for Disease Control and Prevention released new data that show overdose deaths associated with
prescription and illicit opioids increased nationwide to 33,091 in 2015. Explaining that illegal and legal opioids “are intertwined and deeply troubling problems,” CDC Director Tom Frieden said the epidemic continues to worsen.
Some may not see the connection between legal prescription opioids and illegal opiates, yet the link is clear. The New York Times reported a year ago that a stunning 75 percent of heroin addicts used prescription opioids before turning to heroin, a lower cost alternative.
How did this happen? In the early ’90s, there was general undertreatment of pain. “Opiate phobia” — or fear of addiction — kept pain untreated. There was a perception that people who needed opioids were “weak.” Crippling pain from trauma to cancer went either untreated or poorly treated. Then we overcorrected.
By the mid ’90s, the push was on to treat pain. It became the “fifth” vital sign and a marker for quality and patient satisfaction. Pharmaceutical companies created newer versions of short and
long term opiates, and stoked public demand for pain relief and physician guilt for inadequate treatment. The recent push for better “report cards” from patients, as well as fears of liability for inadequate pain relief, led to greater writing of opioid prescriptions. For some bad actors, all out greed led to the creation of “pill mills” which marketed themselves as pain clinics.
A federal Health and Human Services Department report found that in an effort to improve pain management, the increase in prescription opioids led to a significant rise in adverse health consequences, including addiction, abuse and overdose. Against this backdrop, it was inevitable that problems would develop. In the Baltimore area, ready access to opioid pills on the street combined with cheap heroin unleashed challenges affecting professions ranging from public safety to health care providers.
Equally challenging, we cannot simply stop prescriptions. When it comes to chronic pain and the prospect of long term use of opioids among our patients, those of us in the medical community are working to address addiction. Physician groups, such as the Maryland Society of Anesthesiologists (which represents physician anesthesiologists who are board certified and trained in pain medicine) are taking a lead in this process to advocate for patient safety and educational programs.
Where to start? First, the CDC adopted guidelines this spring to appropriately prescribe opioids. Educating the public about the availability of non-opiate pain medicine, therapies, rehabilitation and procedures to alleviate pain is enhanced with the support of the nation’s lead agency charged with protecting public health.
Joining other medical specialists, physician anesthesiologists are raising awareness and defining solutions for prescription opioid abuse. Prescription drug monitoring programs analyze electronically transmitted data by pharmacies and dispensing practitioners. Maryland’s Prescription Drug Monitoring Program became operational in 2013. This system, along with another electronic patient record system that connects 46 acute care hospitals, enables detailed prescription drug history for each patient who will be prescribed an opioid. This system provides interoperability to share health data among Maryland physicians, hospitals and other health care providers.
Physicians are able to access databases prior to writing any prescriptions. Patients who appear to be abusing opioids or other drugs will be monitored and referred for counseling, detoxification or treatment. Future developments will include data analytics to identify patients at risk of abuse so they can be given the resources necessary to ensure safe pain relief.
Physicians take the Hippocratic Oath vowing to “first do no harm.” Current prescribing habits and expectations have indeed caused harm to individual patients, communities and our society as a whole. Physician anesthesiologists are experts in acute and chronic pain management and well accustomed to working in medical teams. This approach has led to continuous improvement in patient safety and reducing anesthesia mortality rates. We will accept nothing less in stopping prescription opioid abuse.
Dr. Amar Setty is a past-president of the Maryland Society of Anesthesiologists and CEO of AnesthesiaStat Consulting, LLC. He is currently on the Maryland Prescription Drug Monitoring Program Advisory Board where he advocates for patients and physicians. As CEO of Patient Premier, he developed the Pain Scored software for monitoring the effectiveness of pain and adherence to a treatment plan. After a merger, it is now also used as part of Montuno’s Dosecast application for pharmacovigilance. Dr. Setty continues as the Chief Medical Officer of Montuno, LLC.