Physicians cannot control patients’ illicit opioid use

Physicians who prescribe opioids are being held partly responsible for the sharply rising rates of opioid abuse and fatal overdoses. The epidemic of opioid overdoes continues to worsen, despite restrictive measures by the DEA, such as the escalation of all opioids to Schedule II, including the least-potent, fixed-dose combination analgesics.

As a result, combinations such as hydrocodone/acetaminophen, formerly on the less-restrictive Schedule III, can no longer be routinely phoned in, nor prescribed in the less-expensive 90-day supplies offered by insurers.

While such restrictions on the availability of opioid pain medications may exert a beneficial effect on reducing the overdose rate, they also inevitably make it more difficult for patients to obtain opioids for the treatment of appropriate diagnosed pain syndromes.

“Illicit opioids” are illegal Schedule I drugs, such as heroin, or Schedule II drugs produced illegally. In recent years, the United States has been inundated with highly potent illegally manufactured fentanyl, which now accounts for the most overdose deaths.

One study of overdose deaths in the U.S. reported that, among the 42,249 opioid-related overdose deaths in 2016, 40.4 percent involved prescription opioids. This finding implies that these overdose victims died as a result of taking opioids prescribed by physicians, perhaps even taking them as directed.

However, the study’s authors were counting in this category all overdose victims who had any detectable prescription opioid in their blood, regardless of whether the opioid was actually prescribed by a physician or obtained illegally, and regardless of how many other drugs were present.

Thus, a victim could take one stolen or diverted 5 mg hydrocodone tablet followed by a fatal intravenous overdose of street heroin, and the overdose would be included among those “involved with prescription opioids.”

Physicians cannot control patients’ access to illicit non-prescription opioids, nor to prescription opioids obtained from illicit sources. Physicians can restrict access to appropriate doses of a single prescription opioid, in restricted quantities, to reduce the risk of overdose. Overdose with only one prescription opioid found in the blood of the victim, and with no other drugs of abuse, often is not reported, making the percentage of overdose deaths involving patients using only properly-prescribed prescription opioids difficult to infer, according to the CDC.

Physicians are frequently called on to treat acute moderate-to-severe pain not relieved by over-the-counter pain medications, but which we know from experience will be at least partly relieved by an opioid medication. We do not know the risk of a given patient ending up as an addict or overdosing if we prescribe an opioid for pain.

We do not know the risk that denying a prescription opioid pain medication will drive the patient into the hands of criminal drug dealers. Doctors risk being blamed for the unknown percentage of patients at risk of addiction and overdose, regardless of what we do, regardless of how prevalent abuse may be in a community.

The NIH and CDC have prepared a guide to prescribing opioid pain medications more safely. Physicians should read and adhere to these guidelines, despite the effort required to perform and document all of the recommended counselling, anti-drug-abuse contracts, pill counting, urine testing, and other potentially insulting measures. Many patients complain that they are made to feel like they are under suspicion.

Doctors and their pain patients will continue to suffer such inconveniences, insults, and financial burdens, until the epidemic of opioid overdoses ends in the United States.

David L. Keller, MD, is an internist in Lomita, Calif.