Like many family physicians, I have witnessed the opioid problem firsthand, seeing some who have inadvertently died, like Prince, from overdose. Deaths from opioids are increasing, and nearly 10 percent of patients who start opioids for something like a knee surgery remain on them six months later, often with worsened symptoms, psychological stress, less effective coping strategies and disability.
We family physicians have rightly been called to follow guidelines to curtail abuse, given that we see one-quarter of all office visits and prescribe one-quarter of all opioids. We must lead the effort to find a comprehensive solution — but everyone has a responsibility.
Pain is a sizable part of medical practice. Pain is complex. Our understanding is limited, its causes are many, and its treatment is challenging. In the 1980s, advocates felt doctors were not taking the relief of pain seriously. Congress responded with the “Decade of Pain Control and Research,” implying that physicians had failed to make pain relief a priority and were “misinformed” about the benefits opioids could provide.
National agencies were swift to incorporate pain management protocols for hospitals, which still exist. “Pain as a Fifth Vital Sign” was touted and hospitals were scrutinized on how well pain was managed, adhering to happy face algorithms to ensure adequate pain relief.
Patient satisfaction scores were collected, creating more happy faces.
Physicians faced scrutiny from their state medical boards, who threatened disciplinary action if patients experienced unnecessary suffering and, in Minnesota, if they were sent to pain specialists. Malpractice cases were brought against undertreating physicians — with charges of patient abuse, some with public shaming and even mandatory psychiatric counseling.
In an effort to find a cure, the Minnesota Legislature recently passed a bill requiring prescribers to maintain access to the state’s prescription monitoring program. I utilize this service, but it is cumbersome and doesn’t integrate with my electronic health records. Removing barriers to accessing information makes sense; mandatory access on every patient every time doesn’t. No studies currently demonstrate a lowering of opioid prescribing with mandatory utilization.
Recently, the Minnesota attorney general suggested that physician training on opioids be mandatory, but most receive education in their workplace. There are limited studies showing that training leads to a decrease in opioid prescriptions, likely because of our limited understanding of the epidemic.
Regulating the scope of practice is a slippery slope, which could lead to mandates on every disease or, worse, cause inadvertent limitation of access to treatment as prescribers drop privileges due to excessive mandates. This would put undue regulatory pressure particularly on family physicians and put the government where it should not be — inside the exam room.
Yes, physicians own some of the blame, but a recent American Academy of Family Physicians study shows that FPs’ first choice for chronic pain management is one of four methods — physical therapy, nonsteroidal anti-inflammatories, acetaminophen, and antidepressants — all before choosing opioids. I can assure you that we would rather not prescribe opioids at all and view them as a last resort.
Some people need pain medications to function and are appropriately treated. What patients really need is access to alternative treatments for pain — mental health care, physical therapy and massage are options that often are not covered by insurance. We must support Medically Assisted Treatment clinics to help addicted patients and allow greater access to and insurance coverage for the antidote Narcan.
Most patients prescribed opioids do not become addicted. Minnesota is ranked 44th in the nation for opioid prescriptions; but we have room to improve. We must be careful about under-treating pain and demand greater patient responsibility with their prescriptions. Physicians are willing to own our role, but this is a societal problem, similar to other “excesses” woven into our cultural fabric — overeating, alcohol abuse, smoking, overspending, the list goes on.
Let’s focus efforts in this legislative session. How do we better recognize those at risk? How can we improve our approach to mental health as it overlaps with opioid abuse? How do we educate society on pain and provide better access to alternative treatments?
As a family doctor, I’m up for the challenge. Are you?
Julie Anderson, of St. Cloud, is a family physician and past president of the Minnesota Academy of Family Physicians.