OPINION: Opioid Prescribing Statistics Don’t Tell the Whole Story

OPINION: Opioid Prescribing Statistics Don’t Tell the Whole Story

Editor’s Note: This story about family practice physicians and their opioid prescribing statistics that ran on the National Pain Report prompted this response from Terri Lewis, PhD.

Terri A Lewis, PHD

Terri A Lewis, PHD

Every time I read an article about opioid prescribing practices it raises a number of issues for me:

(1) What is the role of medical education in teaching physicians how to practice their craft?

(2) What is the role of patient characteristics in the physician’s response to development of plans of care?

I wonder if we don’t have a number of things we should be looking closely into.

There have been conversations raised about the limitations of training physicians in a hospital based environment, with little or no reality testing for the operations associated with practicing in the primary care or specialist community setting.  As the hospital population is understandably sicker, treatment is focused on throwing the necessary resources into levels of patient care designed to get them dismissed from the hospital environment.  This provokes an intense, acute response with a new focus on reduction of readmissions.

The patient who is living in the community however, presents somewhat differently.  Their needs are different, and perhaps the treatment response should be more broadly distributed across the integration of medical practices and community resources.  How do physicians learn to do this when they are not trained in community settings?  Would it be reasonable to assume that hospital trained behaviors may be transferred into the community practice setting?

Could this affect prescribing and treatment patterns?  Is defensive medicine the result of hospital acquired training or the absence of decision skills necessary to practice in the community setting?

Patient complexity in the community setting is wholly different and requires a different response to care than that required in the hospital setting.  Chronicity and complexity are real issues that persist over time and require different decisions and models of care.  Maintenance of function has different outcomes than those associated with cure.  Should improvement of the illness be the standard by which treatment is measured when dealing with chronicity?  Isn’t the real issue that of maintaining function and quality of life in the face of complex conditions that are likely to be present for many years and even until the end of life?  If the physician has not learned how to coordinate and hand off within and between community healthcare and social services, how are they prepared to address the complex patients who enter their practice stream except through over prescribing, over treating, or in frustration, refusing to treat at all?

Finally, can physicians who transfer hospital based decision skills for community focused practice operate with the necessary frame of reference to manage the long term complex care needs of consumers, the expertise of other specialists, or make judgments about the appropriateness of care provided by others?

Are these conditions the result of our current practices in medical education?

Increasingly the evidence indicates that we might have a latent problem that is influencing our interpretation of these matters.

Seems worth taking a close look at to me.

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Authored by: Terri A Lewis, PhD.

There are 10 comments for this article
  1. Richard Oberg at 7:20 pm

    Many great points in these comments but I have somewhat different views often rebuffed since even in-house pathologists aren’t ‘real’ doctors. Despite decades of concerns as to medical care becoming too fragmented, it’s actually become the most fragmented ever. My job was essentially that of being a physician’s physician and, in 30 years of practice, I was very good at it even with my 23 years of ever-present but mostly invisible psoriatic arthritis. As Dr. Radnovich says there’s now segregation of in-house vs. outreach physician training and perhaps that is good – though it proves to be a huge information gap when someone enters the hospital and no one really knows much about them anymore – relaying or asking for information isn’t exactly most physician’s forte. Even among outreach primary care providers there is little to no patient information transfer from one to another as that’s now the job of the patient (in our real world anyway). It’s difficult for us as a two physician family and I have no idea how ‘regular’ folks deal with this (worse care I imagine). I’ve never really understood the problem of ‘lack of education’ as an excuse to poor opioid scripting – they’re potentially addictive, etc. with a side effect profile little different than a huge number of other regularly scripted meds – do they not get regular follow-up like everyone else? We always have and it was expected – so what’s the problem?? I’m very used to co-dependent behavior by physicians inside the hospital and in outreach – can physicians not just say no to patients who don’t qualify for opioid-level management? They were never a substitute for NSAID’s yet seem to be scripted that way. Physicians are also NOT scientists or even critical thinkers for that matter nor does the selection criteria for med school screen for that so no wonder much of the nonsense which is associated with pain meds that shouldn’t be rocket science. I’ve found my physician colleagues to be as biased and bigoted as the general public including the pain med issue which most (being very healthy) seem to think they’d deal with just fine and those requiring pain meds are wimps. Anticoagulants, antiarrhythmics, hypoglycemics, antidepressants, etc. are routinely scripted and can have serious side effects if not followed properly so why the double standard? Terri Lewis is wonderfully eloquent and a well informed ally on this topic. We don’t want to lose the last vestiges of the only medications that give us some comfort (and time for me to write this) but time’s running out and those in power who don’t get it are running the agenda – even if it’s off a cliff for those of us who need regular access to these meds and who’s voice doesn’t seem to mean much.

  2. Cathy True at 5:35 pm

    I have had chronic pain for 20 yrs.My degenerative spine disease is well documented along with the fact that I have always followed all the rules.My family physician would not write my meds under any circumstances since all the talk started a few years ago.He is afraid of doing his job.I have a board certified pain management physician who cared enough about taking the proper care of his patients he returned to school to get a fellowship in his field.He had all the rules in place long before the government,DEA,ect started making decisions for us.Everyone involved needs to be educated before decisions are made.If you have not been trained to understand the difference between acute and chronic pain there is no way you can understand.People who find themselves suffering from pain(chronic) 24/7 must understand what a physician can and can not due.They must understand you can not continually increase pain medications.As a person with chronic pain you have to find ways to cope on a daily basis.Youshould follow all the physicians directions,work with someone if you are suffering from depression,pick hobbies that allow your brain to focus on something besides your pain.You must realize there are those days that your level of pain is so bad nothing you do is going to help.On those days you will probably spend most or all of it in bed.Just try to focus on anything that might help.Chronic pain groups can help you get through that day.Remember,that high level will drop.I live with a pain level of 6 all the time.Those are my good days.Yes,you do loss what was once a normal life.It is a family affair.They have to try to understand what is happening to you.That can not happen overnight.You may loss some friends.They stop calling you to go shopping,out to eat,ect.after you are unable to go.Keep in contact with them.Youinvite them to do something when you are having a good day.Don’t talk about your pain while you are with them.If they ask give a short answer.Again,remember they do not understand.You will make new friends through chronic pain groups.You will have people that relate to you.Again,don’t spend all your time talking about your pain.Find things you all have in common.Good luck to all of you.We must continue to try and get our voices heard.The national pain report has great things going on.You can learn about websites to write to the government agencies who are trying to make these decisions.You even have a guideline to use so you will be heard.Please find these groups.They are well educated people who will help us be heard.

  3. Steve P. at 9:38 am

    My experiences as a Chronic Pain survivor have taught me that the general public and politicians have no idea of the reality that doctors do not know everything. In fact, I know more about chronic pain than most specialists I see and not a one of them researches the latest medical studies or treatments. I personally found all of the new(ish) procedures that I have undergone to help my condition. Why are we relying on doctors, who clearly aren’t doing their jobs? The standard of healthcare has dropped to minimal levels, often requiring several visits for simple conditions before they figure it out. Radiologists have become completely incompetent. In the last 3 MRIs I have had, I personally found multiple issues that were not in the report, which were later verified in surgery. They even once missed a .177 pellet sized cartilage ball between my patellar and femur, that I had notice while watching the images play as a video. 1 family member was killed because a doctor didn’t think to perform a $7 test for infection before surgery, despite treating that family member for the infection 2 weeks prior and another family member suffered a minor stroke and went into shock because the doctor had reduced her opioid pain medication to 1/90th of her normal dose while she was in the hospital recovering from a major spine surgery. I myself was tortured after my patellar-femoral replacement due to a drastic reduction in pain medications while in the hospital. It wasn’t until the physical therapist saw my condition that the problem was resolved, by her dragging an anesthesiologist into the room by their arm. I was left to suffer with effectively no pain management for 8 hours, after having the partial knee replacement. The next time I am calling 911 and hiring a lawyer to press pursue criminal and civil actions. The last I checked the willful torture of another human being or animal is illegal and criminally punishable.

    I and many like me have lost all faith in the medical system and recent political intervention is making the situation worse. Our medical system used to have problems, now it is a disaster that barely functions.

  4. BL at 9:10 pm

    Scott michaels, drs can write you 3, 30 days prescriptions for a Schedule II at one office visit now, but few choose to.

    Joanne, would you please post links to the states that have Laws that restrict the amount of opiates ER drs can prescribe.

    Dr Radnovich, where I live we have a medical school and a teaching hospital with clinics for every speciality. The Pain Management Clinic stopped prescribing opiates several years ago. The Pain Clinic will refer a patient to a Pain Management Dr in the community, but if that person has Louisiisna Medicaid, it will not pay for the management of chronic pain, so it won’t pay for a Pain Management Dr. Very few, if any PCP’s will prescribe opiates for chronic pain to a Medicaid Patient here. If a patient has Medicare or other insurance or can self pay, goiing to a Pain Managment Dr isn’t a problem. Those on SSI for physical disabilities that result in chronic severe pain are left to suffer. Part of my job was working with Medicaid patients.

  5. Terri Lewis at 4:40 pm

    Two recent entries into the virtual world of information release suggest that physicians are not prepared two deal with persons who require the coordination of health care supports for their complex needs. A third suggests progress, but not enough progress.

    The first, a new survey culled data from more than 11,000 primary care physicians in Australia, Canada, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States. The US has the highest incidence of chronic disease, but ranks near the middle or bottom for physician preparedness to deal with this complexity according to responses. In the United States, primary care doctors include general and family physicians, internists and pediatricians.The report exposed gaps in care coordination, communication, access to care and use of information technology across the 10 industrialized nations. Responses indicates the USA ranks from the middle to the bottom in relationship to other countries.

    The second, by Moulds and friends, finds that primary care physicians in ten countries are ill prepared to deal with the needs of an aging population with increasingly complex needs for care. Job-related stress, perceptions of declining quality of care, and increasing administrative burden indicate the need to monitor the outcomes of front-line perspectives as health reforms are conceived and implemented.

    Another survey conducted in 2010, found that almost one-quarter of family medicine residency training programs provided some training in Community Health Centers or CHCs. However, the proportion of residencies providing continuity training in CHCs–the type of training associated with enhanced recruitment and retention of family medicine graduates in underserved areas–was limited and remains relatively unchanged since 1992. While the federal government has called for changes in med ed in several areas, including residencies, some training institutions have been very slow to implement or redesign these necessary adaptations into their curriculums.

    As Dr. Radnovich indicates, there is progress. Whether it is enough progress to keep up with the changing needs of a rapidly aging population is the question. If we are continuing to perpetuate a maladaptive response to the future treatment needs of the population we have, then we need to examine whether we are doing enough or whether we are measuring the indicators that allow us to dial in necessary refinements.

    From the perspective of patients who need coordinated care, our current approaches foster the delivery of too little care in a way that is too late to be effective and indirectly, it may contribute to escalating harm. And even now, the indicators we can measure tell us that we need to be looking closely at these issues as a factor in undertreatment of chronic pain, increasing reliance on unproductive and dangerous use of polypharmacy and fail first approaches. If we have built a system that cannot readily respond to the needs of the population because of the way in which it is designed, then we need to look closely at how to reset this state of affairs.

    As a carepartner, I am shoulder deep in dealing with the effect of these issues. I welcome the opportunity to have this discussion.

    These conversations can be found at these links:

    http://content.healthaffairs.org/content/34/12/2104.abstract?utm_content=buffer69add&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

    http://content.healthaffairs.org/content/34/12/2104.abstract?utm_content=buffer69add&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

    http://www.ncbi.nlm.nih.gov/pubmed/20881687

  6. Kimberly Cornilsen at 11:06 am

    A numbers issue I have is then comparing opioid to heroin death but not including alcohol related death.

  7. Joanne at 11:03 am

    It’s going to get even more difficult for GPs as the states are passing laws restricting the amount of pain medication that can be dispensed in the ER.

  8. Dr Radnovich at 10:36 am

    The days of physician training only in the hospital setting are long gone. Most training programs, especially the primary care specialties, have a significant portion of their training in an outpatient, clinic setting. That’s the good news.

    The bad news: training for pain in both undergraduate and graduate medicine is poor at best. Actually ‘poor’ suggests that there is some training. I am a physician involved in training student physicians and graduate physicians. I hear the same story all the time, that there is little if any training in chronic pain. What training there is tends to be the anecdotal variety of “the majority of chronic pain patients are abusers”. Sadly, each new generation of physicians gets trained in the biases of the previous generation, not the available facts.

  9. Scott michaels at 10:14 am

    i believe a big problem is the insurance companies. when i was with blue shield, i was referred to a pain mgt doc. after 2 months the ins. co. said i could just go to primary, since they are just writting prescriptions. my primary was not trained, so if i had a bad flare up the reply was. im not going to give you stronger pain medication so the would add a soma or valium. Obviously that just veged me out, but i was still in pain. finally afer weeks of arguing with insurance company they allowed me to use the pain doc again. i strongly believe we should use paingt when possible. they should be able wo write 3 month refillable prescriptions for those like me that have been using these meds for over 7 years. Those of us with chronic pain and use opioid therapy responsibly should be grandfathered in if we have been on these meds for over 3 years. now im with kaiser, their pain managent is not pain management. it is like N/A. THEY ARE NOT PRESCRIBING MEDICATION AS A PAIN MGR SHOULD. THAY HAVE ALREADY ADOPTED THE GUIDELINES. I HAD TO FIGHT WITH THEM TO LET MY PRIMARY CONTINUE WHAT MY OLD PAIN DOC MADE WORK FOR ME. FOR NOW ITS OK BUT HE KEEPS WARNING ME THAT LAISER WILL ADOPT THESE VOLUNTARY GUIDELINES. ITS GOING TO SAVE THEM A FORTUNE!

  10. D Parker at 10:00 am

    A very astute point.
    Chronic disease sufferers do expect and depend on primary care physicians to know the proper treatment modalities.