Battle against opioids sparks worries about unintended consequences

USE OF opioid alternatives for pain is surging as the U.S. tries to stem abuse of the addictive painkillers, giving physicians concern that the opioid crisis will be superseded by a new prescription drug epidemic.

Nearly two-thirds of primary-care physicians shared that sentiment while nearly three-quarters worry that chronic pain patients will turn to illicit drugs if they don’t have access to prescription opioids, according to a new report from Quest Diagnostics, which polled 500 primary-care doctors and analyzed 4.4 million lab test results. The report reflects physicians’ apprehension that the healthcare system is ill-equipped to properly transition from overutilization of opioids.

“What most fail to realize is that we have a dual crisis in this country,” said Dr. Jeffrey Gudin, a senior medical adviser for Quest and a pain management specialist at Englewood (N.J.) Hospital and Medical Center. “There is no question that people misuse substances that make them feel good, but there is also a crisis of chronic pain, for which there is no cure.”

Providers worry that the opioid manufacturing caps and restrictions from insurers and providers are cutting off the much-needed supply for cancer patients and others with chronic pain.

It is considerably harder to treat chronic pain patients, 83% of physicians surveyed in the report said. A similar share said they are reluctant to take on patients who are currently prescribed opioids. “Not a day passes that a patient doesn’t shed real tears about having opioid doses tapered,” said Gudin, adding that guidelines the Centers for Disease Control and Prevention issued in 2016 led to a widespread reduction in opioid doses without alternative treatment options.

More than 70% of doctors said that although there will likely be a decrease in opioid-related deaths, more patients will not have their pain properly managed.

Meanwhile, gabapentin—an anticonvulsant that can be used to relieve neuropathic pain and is often prescribed as an alternative to opioids for managing chronic pain—was detected in more than half of opioid overdose deaths, according to the CDC. Quest’s data show that 13.4% of patient test results showed non-prescribed gabapentin in 2018, up from 9.6% in 2017. Gabapentin trailed only marijuana and alcohol at 14% each.

There needs to be a more comprehensive plan addressing emerging drugs like fentanyl and other alternative pain medications, said Dr. Georges Benjamin, executive director of the American Public Health Association.

Gabapentin is one of only three drug groups for which misuse—often in improper combinations of drugs—increased from 2017 to 2018. The other two were alcohol and non-prescribed fentanyl. Physicians were also concerned about the abuse of benzodiazepines and amphetamines.

“Pain patients have learned if their psychiatrist gives them Valium, then they don’t tell their doctor because they won’t give them opioids,” Gudin said.

Physicians may be overconfident in their ability to recognize prescription drug misuse, and drug mixing is often underestimated, the report indicated. Nearly all doctors felt confident in their ability to discuss risks associated with prescription drug misuse with patients, but only 55% said they actually addressed it with most of their patients who were prescribed controlled substances in the past month.

Physicians recognized that they need help monitoring prescription drug use. At least 7 out of 10 doctors said that they wish they had more training on how to taper patients off opioids, when to refer patients to pain specialists, how to spot addictive behavior and what to do after the fact.

Prescription drug monitoring helps, the vast majority of physicians said, but half indicated that there are cost and access obstacles.

Many chronic pain patients would benefit from multimodal treatment, including non-pharmacologic therapy, said Dr. Michael Ellenbogen, assistant professor of internal medicine at Johns Hopkins School of Medicine.

More patients are using acupuncture, physical therapy, massage and other pain-management alternatives, although payer coverage issues remain, Gudin said.

“These are things that are not taught in medical school,” he said. “I think the medical society needs to do a better job educating doctors on the front line, which are primary-care clinicians.” ●

83% of physicians surveyed in the report said it is considerably harder to treat chronic pain patients