Pubdate: Tue, 03 Jan 2017
Source: Boston Globe (MA)
Copyright: 2017 Globe Newspaper Company
Contact: http://services.bostonglobe.com/news/opeds/letter.aspx?id=6340
Website: http://bostonglobe.com/
Details: http://www.mapinc.org/media/52
Author: Felice J. Freyer

DOCTORS CURTAIL OPIOIDS, BUT MANY SEE HARM TO PAIN PATIENTS

Doctors are being more careful with opioid prescriptions as addiction and
its effects get more recognition.

More than half of doctors across America are curtailing opioid
prescriptions, and nearly 1 in 10 have stopped prescribing the drugs,
according to a new nationwide online survey. But even as physicians
retreat from opioids, some seem to have misgivings: More than one-third of
the respondents said the reduction in prescribing has hurt patients with
chronic pain.

The survey, conducted for The Boston Globe by the SERMO physicians social
network, offers fresh evidence of the changes in prescribing practices in
response to the opioid crisis that has killed thousands in New England and
elsewhere around the country. The deaths awakened fears of addiction and
accidental overdose, and led to state and federal regulations aimed at
reining in excessive prescribing.

Doctors face myriad pressures as they struggle to treat addiction and
chronic pain, two complex conditions in which most physicians receive
little training. Those responding to the survey gave two main reasons for
cutting back: the risks and hassles involved in prescribing opioids, and a
better understanding of the drugs' hazards.

The results also suggest a substantial minority of physicians may believe
the pendulum has swung too far, depriving pain patients of needed relief.

"Pain management is incredibly complex," said Dr. Lynne M. Lillie, a
Minnesota family physician and member of the board of directors of the
American Academy of Family Physicians.

Team-based pain care that empowers aching patients is effective,
inexpensive - and hard to get.

Now, Lillie said, keeping track of evolving science and state and federal
guidelines add to the complexity. "For some people, they are simply having
to say, 'It's too much. I can't be all things to all people,'" she said.

As policy makers sought to tackle the abuse problem, "the physicians were
an easy group to target," said Dr. Joseph Audette, chief of pain
management at Atrius Health, a large Massachusetts medical group. But the
regulations won't solve the addiction problem, he said. Instead, they make
doctors reluctant to prescribe opioids.

"A lot of primary care doctors feel like they can't comply. They're
overwhelmed," Audette said.

The four-question survey was conducted Dec. 15 through 22, sent by e-mail
to doctors across the United States by SERMO, an online community that
enables physicians to anonymously share ideas and concerns. SERMO
periodically taps into its worldwide membership of more than 600,000 to
conduct opinion polls; for the Globe's survey, the company randomly
selected 25,000 American doctors. Nearly 3,000 replied.

Just over half of all respondents had cut back on opioid prescribing
within the past two years or so, while more than two-thirds of family
medicine and internal medicine doctors had done so.

The percentage who believed patients had been hurt by reductions in
prescribing differed little among specialties: 36 percent of all
specialties, 38 percent of family doctors, and 34 percent of internists.

Still, nearly three-quarters of respondents believe chronic pain patients
have adequate access to treatments other than opioids. Cindy Steinberg, a
national advocate for pain patients, speculates that doctors probably
don't follow up after referring patients to other care, and may not know
that many can't afford it.

Although it's unknown whether those who chose to reply to the survey are
representative of physicians overall, the findings align with other data
showing a reduction in opioid prescribing.

Dr. Stefan G. Kertesz, a professor at the University of Alabama Birmingham
School of Medicine, has witnessed the downside of that trend: chronic pain
patients who have essentially been abandoned by their doctors in the
stampede away from opioids.

Kertesz recently published an article in the journal Substance Abuse
showing that physician prescribing no longer plays a major role in
sustaining the opioid epidemic, which is now driven by heroin and illicit
fentanyl.

"But public discourse has been contaminated by aggressive and inflammatory
language that frightens doctors," he said in an interview. Even
specialists in addiction, while agreeing doctors should be cautious about
prescribing opioids, also "fear that doctors are pulling back in a chaotic
way that could be harmful to patients," he said.

Dr. Laura J. Simpson, a family medicine physician in Marblehead, sees
benefits in the publicity about opioids' harms: It paves the way for
doctors to discuss why they won't write a prescription for every pang.

"People now understand. They don't see it as you just not helping them,"
she said.

And Dr. Rebecca Andrews, a University of Connecticut medicine professor
and internist practicing in Farmington, Conn., predicts that eventually
the concern over opioids will lead to improved care, by deepening
doctor-patient conversations about managing pain and pointing to the need
for alternative treatments.

The decline in opioid prescribing is steady and nationwide, according to
data from athenahealth, a Watertown company that provides electronic
medical records.

In Massachusetts, doctors and nurse practitioners using athenahealth
software, who already prescribed lower amounts than their peers
nationally, made even steeper cutbacks.

In Massachusetts, the number of athenahealth patients receiving an opioid
prescription dropped from a high of 6.9 percent in early 2015 to 5.3
percent as of Dec. 1. Nationally, prescriptions declined during that
period from 8.7 percent to 7.8 percent.

But despite low prescribing rates in Massachusetts, the state has one of
the highest rates of overdose deaths. Those deaths continue to increase -
the vast majority resulting from illicit drugs.

Thus the effort to further restrict opioid prescribing amounts to "a case
of generals fighting the last war," said Dr. Stephen A. Martin, a family
physician in Barre and University of Massachusetts Medical School
professor publicly calling for a recalibration of attitudes toward the
drugs.

Opioids are often a poor choice for treating chronic pain, and most
specialists agree that past prescribing practices were too lax. But
opioids work for some patients who can safely take a steady dose, and rely
on the drugs for daily functioning.

Steinberg, who leads a chronic pain support group in Arlington, knows many
such people whose doctors are taking them off opioids against their will.
One member of her group has a severe spinal injury and now faces the loss
of the one daily Percocet she relies on to sleep.

"In many cases, doctors are walking away completely. They don't even want
to see patients in chronic pain," said Steinberg, the policy council
chairwoman for the Massachusetts Pain Initiative , a nonprofit concerned
with improving the lives of people in pain.

She implores doctors who curtail opioids to "partner with your patients
and stay with them to help find other options."

"It's frightening," Steinberg said, "to be living in that kind of pain and
not have help."
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