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In the opioid crisis, doctors rethink pain treatment

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Dr. P. Tennent Slack treats a patient for thoracic joint arthritis pain during a procedure where he injects a steroid based numbing medication on Nov. 17, 2016 in Braselton, Ga. Slack is a pain medicine doctor who practices in Gainesville and Braselton. He has been a prominent voice in Georgia about the need for doctors to be more thoughtful and discriminating when prescribing pain medications. (Bob Andres/Atlanta Journal-Constitution/TNS)

Don Teater didn’t start out declaring war on opioids. As a small town family doctor, he prescribed them.

“I heard the message from the pharmaceutical industry and the government and others that we weren’t treating pain well enough, that we need to prescribe more opioids — and that it was very safe,” Teater said.

So, like most doctors in America, he embraced opioids as a long-awaited answer for patients suffering with pain.

Before long, in the exam rooms in his western North Carolina office, Teater saw the dark side of pain pills. Some of his patients, once they started opioids, had a terrible time getting off of them. Others got lost in all-out addiction. Teater decided to try to attack the problem by offering addiction treatment and was overwhelmed with patients seeking his help.

When he took their histories, he heard over and over again how it all started: A doctor told them to take an opioid for pain.

And they did.

Today, Teater, who never felt comfortable in the spotlight, has become a passionate voice calling on his colleagues to stop doling out the pills. In hotel ballrooms at conventions and at medical society meetings, he tells anyone who will listen that the drugs are dangerous. But he also tells them something that’s not so well known and that some other doctors dispute. He tells them the pills don’t actually work as well as most physicians think.

“The drug companies like to use to the word painkillers,” Teater said. “They are not painkillers. They temporarily elevate our mood, and that’s the best way they work.”

While opioid painkillers were initially billed as safe and the most effective option for all types of serious pain, more and more evidence is suggesting that they may not live up to either of those claims. Even so, many doctors across the nation still use them as a matter of routine. In Georgia alone, patients were prescribed more than 541 million doses of opioid painkillers in a recent 12-month period. That’s 54 legal doses for every adult and child in the state.

“I believe at least 90 percent, maybe 95 percent, of opioids are probably inappropriately prescribed where there are better, safer alternatives that are not opioids,” Teater said.

While pill mills and rogue doctors have handed out millions of pills for no medical purpose, well-meaning physicians who were trained to aggressively treat pain are also a big part of the problem.

With such a heavy focus on treating pain, prescribing opioids for years seemed to be the responsible route.

Once patients start on opioids, they may want to stay on them. The pressure to keep prescribing can be intense when it plays out in the intimacy of an exam room, or when doctors work for a health care system that evaluates them using patient surveys and reviews.

Besides, there seemed to be little downside to providing the painkillers.

Tom Frieden, the former director of the Centers for Disease Control and Prevention, said many doctors were told for years that patients taking opioids for pain would not become addicted to them. “It’s completely wrong, but it’s how a whole generation of physicians was taught and, obviously, we need to reverse that,” he said.

The truth is, Frieden said, that some patients can get addicted to opioids after just three days of taking the pills.

“Any time a doctor writes a prescription for an opiate, they should be asking the question: Is this the first time this patient had gotten an opiate? And, if so, is it really absolutely necessary? Because this is a momentous decision. A first-time prescription for an opiate may condemn a patient to a lifetime of addiction,” Frieden said. “There are very few medications that we use that kill people as often as opiates.”

Research suggests there’s still a place in medicine for these powerful painkillers, Frieden said. It’s just not the widespread use reflected in the prescribing patterns of both yesterday _ and today.

“If you’re in great pain from a car crash or surgery, opiates certainly work, and they reduce the pain,” he said. “We do not want to deny people palliation if they are in severe pain. That’s a very important function for opiates.”

But Frieden, now the CEO of Resolve to Save Lives, a global health initiative, said the question about whether opioids work for chronic pain that afflicts people for months, or even years, comes with a much different answer.

“They will certainly reduce the pain in the short term, there is no doubt about that,” he said. “But it’s completely clear that for chronic pain they are much less safe than other medications, and it increasingly appears to be the case that they are also less effective than other medications in the medium and long term.”

 

This year, Erin Krebs announced early findings of one of the first rigorous research projects to test the effectiveness of opioids for treating chronic pain.

It’s not yet been published, but at the annual meeting of the nation’s general internal medicine doctors, Krebs shared the key revelation.

“Our main finding is that opioids were not better than non-opioid medications in this study,” said Krebs, who practices medicine and conducts research at the Minneapolis VA Health Care System. “We found that most people were able to manage their pain just as well with use of non-opioid medications.”

It’s a stunning finding for many patients and doctors. “It’s hard to overstate how jarring this change has been for many practicing physicians,” Krebs said. “It’s been a really rapid reversal in terms of the advice they are getting.”

The finding put many doctors in a quandary.

At a congressional hearing this fall, Rep. Michael Burgess, who is a physician, posed the question to the expert panel. “What’s a doctor to do?” he asked. “You have a patient that has a condition that is painful and you want to alleviate that suffering. How do you approach that? Are you not going to use an opiate?”

In response, Scott Gottlieb, the U.S. food and drug commissioner, testified that practices of the past had to change. For example, he said, standing orders for anyone in the hospital to get Percocet, if a nurse believed a patient to be in pain, may have been well-intentioned but were wrong. “That wasn’t good medical practice, we now know,” he said.

After just five or six days of exposure to painkillers, Gottlieb said, “some of those patients left the hospital addicted.”

The medical community, he said, must reconsider how these medications are used. “We’re in the process of doing that,” he said. “That’s also going to require us to re-educate a generation of physicians, and that’s what we’re doing.”

P. Tennent Slack, a pain doctor who practices in Gainesville and Braselton, Ga., said there’s no question that too many doctors have been “indiscriminate” in their prescribing of opioids.

Prescribing an opioid should never be a quick, easy solution, Slack said. It requires a close evaluation of the patient’s pain and an honest assessment of the patient’s risk of addiction. In every case, Slack said, doctors should consider the alternatives, from the least invasive to the most invasive — surgery. When opioids are used, he said, doctors should prescribe the lowest effective dose for the shortest amount of time.

Slack worries, though, about the unintended consequences that could come from the urgent push to address the opioid crisis. He advocates a solution that balances the need for more careful prescribing with an acknowledgement that some patients do well on the medications and would suffer without them.

“The vast majority of Americans take the opioid pill and they stop,” he said. “There are those who make it sound like everybody who is exposed to a narcotic will undergo some sort of change in the brain that will cause them to misuse the medication.”

About 97.5 million people across the nation used prescription pain relievers in 2015, according to the 2015 National Survey on Drug Use and Health. Of those, 87 percent used them as directed, and 13 percent misused the medication. About 2 million people have a substance use disorder involving pain pills.

Slack, whose guidelines for being a “discriminating prescriber” are detailed and demanding, said he has some patients with debilitating pain who do well on opioids. These patients can work, take care of their children or walk comfortably with the help of pain medications, as long as they are prescribed with care and careful monitoring, he said.

His goal is to make sure these patients aren’t forgotten in the discussion. “The pendulum is headed so far back in the other direction, we’re going to see overly restricted access to opioid therapy to the point there will be some unnecessary suffering out there,” Slack said.

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