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The opioid prescriber’s dilemma 1

The opioid crisis has been devastating to individuals, families and communities across the country, but how did we get here? In medicine, there has long been a tension between the risks associated with opioid use and the need to treat pain.

The rise of opioid use

Historically, concerns about this class of drugs commonly led to minimizing their use except in chronic conditions toward the end of life. In the 1980s, the tide began to shift with a move from using opioids to treat cancer-related pain, to using them to treat chronic non-cancer pain. By the 1990s pain had become the “fifth” vital sign and in 2001 the Joint Commission, a standards development and accreditation body, created a standard requiring a pain assessment on all patients.

I personally saw the desire to treat all pain, or even potential pain, aggressively when my then two-year-old daughter was prescribed liquid Vicodin (a powerful opioid) following a minor surgical procedure.  I thought, why give a potentially addictive narcotic to a toddler when ibuprofen would be a safe and effective first-line approach to managing her pain?  I should note that she never received the medication, but the pendulum had clearly shifted, maximal pain control had become a primary priority.

The consequences of rising opioid prescriptions have been devastating; the Centers for Disease Control and Prevention (CDC) reports that prescription opioid use and overdoses have quadrupled since 1999. More than forty Americans die every single day from overdoses involving prescription opioids.

To prescribe or not to prescribe opioids?

The change in prescription patterns certainly helped fuel the crisis. Healthcare is responding in multiple ways—one of which is assisting with the prescribing process. Physicians make a fundamental decision each time they write an opioid prescription: Do I write the prescription and risk fueling addiction, or do I withhold the prescription and risk undertreating someone who really needs help? Each prescription is a judgment call. There is general agreement that the broader healthcare community went too far in shaping those judgments, and in 2009 the Joint Commission removed the pain assessment standard.

Technology has and will continue to play a role in facilitating a safe, secure prescribing process. It can:

  1. Compile information from across the continuum of care. Knowledge is power. Prescribers should have access, within their workflow, to a patient’s history with controlled substances through state Prescription Drug Monitoring Program (PDMP) databases, no matter where that patient was seen.
  2. Bring “red flags” to the prescriber’s attention. Use alerts and other means to bring needed information into the prescribing process.
  3. Enable safe prescription transmission. Most physicians have stories about altered paper prescriptions. For example, editing a quantity from “3” to “30,” or stealing pages from an unattended prescription pad. Electronic prescribing of controlled substances can help mitigate some of these risks by ensuring that the pharmacy receives what, and only what, was prescribed.

Technology and its role in helping combat the opioid crisis continues to evolve. As we develop solutions, we must continue to present information in a way that enables prescribers to make the best decisions they can.  We won’t be realistic if we try to develop a system where physicians never, ever prescribe an inappropriate opioid. In that situation, there is a substantial chance of undertreating some patients who would genuinely benefit.

While additional efforts will be needed to address the breadth of the problem, continued focus on education and delivering tools that help clinicians make their best judgments for patients will go a long way to help address the ongoing opioid crisis.

Editor’s Note: To hear more from Dr. Blackman on this topic, download his recent podcast What Caused the Opioid Crisis?

1 Comments

Comments (1)

John Vaughan III

I appreciate your perspective on this topic. I just wish more physicians would chime in and that may be already occurring. However, great to hear from a source who not only represents the physician realm but someone who has actually somewhat experienced the shift in medical prescription practices.

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