Pain — unlike, say, blood pressure — is not a simple thing to measure.
Though just as real, clinicians note that the experience of pain is subjective, varying from patient to patient. Not surprisingly then as the rate at which opioids are prescribed has skyrocketed following a push to better treat pain, there’s wide variation in how frequently doctors recommend the powerful pain narcotics — from oxycodone to fentanyl.
Opioids can have serious side effects — from nausea and vomiting to increasing fall risk, particularly in the elderly — and are highly addictive. And in an effort to curb overuse, the marked differences in the rate at which some doctors prescribe opioids has become a point of focus.
[See: 11 Ways to Cope With Back Pain.]
Doctors Vary Widely in How Frequently They Prescribe Opioids
To better understand the extent to which physicians vary in opioid prescribing — and the implications for patients — research published this month in the New England Journal of Medicine evaluated this variation within emergency departments. The research reviewed data for Medicare patients who hadn’t received prescriptions for opioids within six months prior to that emergency room visit. “ER physicians are more or less seeing a random sample of patients” within a given hospital, says lead study author Dr. Michael Barnett, an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health in Boston. In addition, he notes that the emergency room is a common place for opioids to be prescribed.
The results showed wide variation in how frequently different doctors prescribed opioids. Even within the same hospital, ER physicians varied by three-fold in the rate that they prescribed opioids to Medicare patients, Barnett says: “from 7 percent to 24, which is a really wide gulf.” In other words, about 1 in 14 Medicare patients studied who were seen by a a so-called “low-intensity” opioid prescribing physician in the ER got a pain narcotic prescription, while”high-intensity” prescribers put roughly 1 in 4 Medicare patients on opioids, according to an evaluation of prescription claims data examined after the patients left the ER. Patients who saw a high-intensity opioid prescribing physician were 30 percent more likely to use opioids long-term — or for at least six months in the subsequent year following their visit to the ER.
Additionally, physicians were classified according to the median dose of opioids they prescribed, measured in morphine equivalents. “We found that there was also a 30 percent higher rate of long-term use among patients treated by high-dose physicians,” Barnett says, compared to physicians who typically prescribed a low-dose of opioids.
“The takeaway for patients is that even a single opioid prescription carries quantifiable risks for developing risks for long-term use,” he says. Among the limitations of the research, it didn’t establish a cause-and-effect relationship between physician prescribing habits and patient’s long-term use of opioids, or determine whether that contributed to addiction. “We can’t say how strong of a relationship it has to addiction or dependence,” Barnett says. “But I think most people would still view that as a negative outcome, if it’s potentially preventable without undertreating pain.”
[See: Your Guide to Over-the-Counter Pain Relief.]
Do You Need a Prescription Narcotic for Your Pain?
Experts say before taking an opioid, patients should first discuss with their doctor the risks and potential benefits, as well as the perceived need for the pain narcotics; alternative options to treat the pain; and — if the doctor feels strongly that an opioid is needed — whether a lower dose would suffice and how long it should be taken. Often, experts say, over-the-counter medicine is sufficient to address pain or discomfort.
Patients who leave the hospital with an opioid prescription should also take additional steps to proceed with caution. The NEJM study suggests that if patients fill the opioid prescription, they’re more likely to continue to be prescribed opioids, says Dr. Ajay Wasan, vice chair for pain medicine at University of Pittsburgh Medical Center. “One implication of the study is that it might be better to wait, and if the pain gets worse, then fill the prescription,” he says. “This strategy might reduce the chances that a patient might be continued on opioids long term.”
Unlike when patients are advised to take other drugs to address asymptomatic health issues, such as controlling blood pressure, experts say the point of opioids is to address the symptom of pain. So patients should use their own discretion based on their level of discomfort and their pain threshold, and needn’t take all pills prescribed either.
“Federal law now allows a partial filling of an opioid prescription, with the unfilled balance being available within 30 days,” says Lowell Anderson, a professor of pharmacy practice at University of Minnesota’s College of Pharmacy. “This partial filling option contributes to the reduction of unused medications sitting in the medicine cabinet and ultimately being used by someone other than the patient or disposed of in the environment.” He notes there may still be some state restrictions since the federal law took effect last year.
He adds that patients shouldn’t try to get the maximum number of tablets or capsules that their health plan allows — whether that’s a 30-, 60- or 90-day supply. “Rather limit [it] to a responsible quantity,” he says, since you can always request another prescription if needed.
Patients who have struggled with past addictions — including to drugs or alcohol — should be particularly cautious in treating pain with opioids. Though doctors should be asking about such risk factors, in medical settings where patient-doctor interactions may be brief — from the ER to the primary care office — that’s not always done, says Dr. Shawn Ryan, president of the Ohio Society of Addiction Medicine. States also have prescription drug monitoring programs through which doctors and pharmacists can see if patients have filled prescriptions for opioids and other controlled substances elsewhere and be more alert to signs of a potential problems like opioid abuse.
Even if it’s uncomfortable to have the conversation with a doctor, discuss any concerns about misuse, abuse or long-term dependence on opioids upfront if the drugs are recommended to treat pain, experts say; ask, too, about ways to reduce risk of addiction, misuse or abuse. These may include shortened prescriptions, abuse-deterrent formulations (that can’t be easily crushed or snorted, for example), longer-acting medications and family member mitigation strategies, where appropriate. So if the family member, like a spouse, knows a loved one has an opioid use disorder, he or she may control the release of the medications to help prevent misuse, Ryan says.
[See: How to Help Aging Parents Manage Medications.]
In addition to speaking with the health provider who prescribes the opioids, he recommends patients who haven’t taken opioids previously do their homework in reading educational materials, like those from the Centers for Disease Control and Prevention, that offer guidance on taking the medications properly. Before refilling a prescription, experts say, take time to speak with a health provider who knows you best — typically a primary care physician — about whether it’s appropriate to continue on the medications.
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Should You Fill That Opioid Prescription? originally appeared on usnews.com
