May 21, 2019

A Call for Education on Opioid Prescription

By Scott Bradley, MD

A growing fear of prescribing opioid painkillers has, unfortunately, also had a negative impact on chronic pain patients who truly need these medications to function. 

To ensure that opioids remain in our toolbox for the right patients, physicians of all specialties must fully educate themselves on current federal and state regulations, and learn how to use the therapies safely and consistently. This knowledge base should relieve anxiety about potentially making a wrong step and facing disciplinary action. 

Undeniably, our country has a serious problem with opioid abuse that we must address. Over-prescription of these narcotics, particularly during the 1990s and 2000s, fueled those trends, and a smaller number of medical professionals today do continue to rely too heavily on opioids. 

Yet it is also important to note that most overdoses and deaths are linked to illicit use of fentanyl and heroin. We shouldn’t forget that opioids still can provide great benefits when used wisely: after exhausting other treatments, with safeguards in place and in conjunction with needed lifestyle changes.  

For patients with severe degenerative conditions, other rheumatic diseases such as Ankylosing Spondylitis or Rheumatoid Arthritis, or connective tissue disorders such as Ehlers-Danlos syndrome, opioids can be the difference between a normal, stable life and a crippling disability. Sadly, cutting people off from medication has ultimately led to suicides in some cases.  

I urge all physicians to take these steps: 

• Study Virginia Board of Medicine guidelines. Visit www.dhp.virginia.gov/medicine and read “Regulations Governing Prescribing of Opioids and Buprenorphine.” This document is updated as of August 2018 and incorporates rules from federal agencies. 

• Carefully document a patient’s need. Record all previous treatment strategies, which might include anti-inflammatories, steroids, physical therapy and/or ice and heat therapy. Also describe in detail the functional limitations that a patient’s pain is causing and why medication, especially if a higher morphine equivalent dosage, is necessary.  

• Use the Opioid Risk Tool. This brief screening test helps predict an individual’s risk of opioid abuse – mild, moderate or high – based on personal/family history of substance abuse; age; history of sexual abuse; and presence of a psychological condition such as Attention Deficit Disorder, bipolar disorder, schizophrenia or depression. This is another way for doctors to back up a decision. 

• Use urine screens. Test regularly to ensure exact compliance with a prescription, and to uncover the presence of any illicit drugs. 

• Empower patients. Opioids do become less effective over time, so patients should never consider pills as a “quick fix” or their only treatment. Instead, they must commit to lifestyle approaches that also will fight pain, such as a healthy diet and regular exercise.  

• Refer patients for needed mental health care. Like any drugs, opioids can be used as a coping mechanism for underlying issues. If you’re suspicious, don’t be afraid to ask hard questions. 

• If weaning, do so carefully. The usual guideline of about 10 percent reduction in dose each month generally should apply. Go slow, and support and encourage your patients.  

While physicians may be tempted to refer their chronic pain patients to a specialized clinic or practitioner, the better choice is to educate yourself. You can protect your practice without giving up your responsibility to help your patients, and work to offer effective relief without fear.

Scott Bradley is a Board-certified and Fellowship-trained physical medicine and rehabilitation physician with Hampton Roads Orthopaedics & Sports Medicine, based in HROSM’s Williamsburg office. hrosm.com