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The Truth about Overprescribing and the Opioid Epidemic


Overprescribing - Just don't start

The charge against me is of overprescribing, which is a legitimate public health concern in our state, since historical overprescribing likely contributed to an increase in overdose deaths in the first decade of this century. There were new guidelines(external link) published by the Medical Board of California in 2014 that recommended not increasing pain patients offered a trial of opioids beyond a total daily opioid dose of 120 mg MED, and made a number of other recommendations for safe prescribing. The CDC published similar guidelines(external link) in 2016.
These guidelines were intended to guide initial therapy, and I have absolutely complied with those, not starting and increasing opioids beyond this dosage range. In fact, most of my patients know I try to work with patients to find alternatives and not start opioids at all for chronic pain. See the slides from my 2014 talk at NCAMHP(external link) for my philosophy about opioids for chronic pain - I see them as a bridge to increase activity, but not a long-term solution.

Legacy Patients - correcting past errors vs. throwing away the victims

The issue at hand, however, is whether the guidelines are applicable to pain patients who were historically treated with higher doses of opioids, before the potential harms were fully understood, and what the strategy should be to lower doses towards the guideline limits in these patients. Many physicians have simply dumped these patients or rapidly tapered in order to protect their licenses, but I do not believe this care protects the patients or is the right care for these patients. As the CDC has recently clarified, I believe the guidelines have now been misapplied in the setting of Legacy Pain Patients, and a number of experts agree. That said, some of these patients have problematic behaviors, and it is certainly possible, or even likely, my judgment has not been perfect in this regard. The one thing I can say is that I have earnestly tried to pick the path of the least harm, to the best of my ability to identify that path.

Why were these patients on Pain Medications?

These patients are not just addicts, who are taking the medication for no good reason. As an example, see the hip joints (or lack thereof) in P1(Posted with her consent):

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The xray on the left is of a patient with normal hips (the dark space between the thigh bone and pelvis is where the cartilage is.) On the right is the image from P1. Her daughter reported that the orthopedist “in Fortuna we saw recently took one look at her x-rays and could not even believe she was able to stand. He said looking at her x-rays he would expect her to be completely bedbound and was shocked at her fortitude. That is the thing about my mother, she is stubborn as a mule, however the pain is almost unbearable for her."

Why not just taper them down by 10% per week or month as the California guidelines suggest?

There are a number of potential harms to forced and rapid tapers, including turning to illicit sources (heroin and pills from the streets), suicide, and significant loss of function of these patients. Just as an example, I took this figure from the CDC website on the rise in overdose deaths(external link) And added some additional data (in red) also from the CDC website about decreases in opioid prescribing(external link)

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I do not feel it takes a genius to see that forcing patients to drop their doses abruptly is NOT preventing opioid deaths, in fact, perhaps the contrary. Most of my patients are somewhere in a taper process, but I actually monitor that process, rather than announcing it and proceeding regardless of response.

There are a great number of stories locally and elsewhere of people who were tapered on a fixed schedule and have:
1. Lost function and independence
2. Contemplated or committed suicide - there is a blog devoted to these cases(external link)
3. Turned to illicit sources of medications – heroin or pills purchased on the streets. Even the pills can have fentanyl in them so this is a very dangerous situation. (I saw a recent slide of a pill that appeared to be Percocet which was found to contain fentanyl.)

Alternative to a Forced and Rapid Taper

I have a different approach, which I have been developing and honing over the years, and which I believe is more effective and less risky, though certainly more work, often frustrating, and not always successful. To paraphrase Churchill, "Patient-centered care is the worst form of medicine, except for all of the others." I will let my patients speak for me in some of their Letters of support.

The word doctor comes from the Latin word "docere" meaning "to teach." I think my job is to teach patients about the potential harms of opioids (which include hormonal disruption, mood changes, even INCREASES in pain through hyperalgesia), to help them understand underlying causes of their pain, which include physical injuries but also past trauma and current stressors, to provide them other tools to deal with those things, and inspire them to want to decrease medications. A similar approach is used in treating addiction, to explore the patient's own ambivalence and let them tell me the reasons they want to change.

The Patients in the Complaint

For the patients in the complaint:
MED at Initiating care with meMED now 5/27/2019
14400
937.5590
Butrans 20 (More than 80 MED)35
720693.8
165 Increases related to surgeries and attempts to modify regimen, then tapering 110

MED = Morphine Equivalent Dose

For these patients, when we were attempting taper and adverse events occurred, we backed up and decreased the speed of taper. When they developed new problems like cancer or had surgery, the doses went up temporarily.
There were times when things I tried did not work as intended. I cannot state that all of my decisions are perfect, but I did track the results of what I did, and correct course when there were problems.

Benzodiazepine use

I DO NOT START OPIOID-DEPENDENT PATIENTS ON BENZODIAZEPINES. These patients arrived on these medications. I have encouraged all of my patients on benzodiazepines to taper (as several of the patient letters on the website can attest.) I would certainly have preferred that they do that more rapidly than they did, and am of course looking at ways to be more effective with such patients in the future.

Despite the inflammatory language of the complaint, I believe the patients involved were extremely tolerant to these medications and not in immediate danger, though two of them were clearly overmedicated and had to be tapered. At the same time, IT IS DANGEROUS TO STOP THESE MEDICATIONS SUDDENLY. I looked for alternatives that would control their symptoms and allow them to taper the medications in question, but this is the element of care that I do have the greatest regrets about, that I was not more creative in finding ways to limit medication overuse in patients who were at times making poor decisions.

Medication Interactions

Benzodiazepines and opioids are a relatively contraindicated combination of medications. I receive transfer patients on contraindicated combinations all the time, including migraine medicine with antidepressants, a recent hypertension patient placed on clonidine and a beta blocker together, and so on. My most common intervention when a new geriatric patient comes to the practice is to look at their regimen and stop the medications that may be making them worse.

I occasionally prescribe relatively contraindicated combinations of medications myself as well, with monitoring for the possible sequelae of the interaction. When I have a patient on a statin who needs an antibiotic that interacts, we lower the dose of the statin or even hold it for the duration of the antibiotic. This is standard medicine, to balance the risks and benefits of medications and monitor the response. As stated, when patients were having side effects, I tapered them, but did not cut them off.