Questions and Answers for Clinicians Facing the Opioid Epidemic

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Medical doctors, inadvertently and meaning to serve their patients, too often overprescribed opioid pain pills, like OxyContin, Vicodin, and Percodan. Coupled with misleading information about the safety of these drugs and a growing focus to not undertreat pain, the opioid epidemic began. The plague of overdose deaths continues today. Doctors need to be part of the solution, and we can be.

With any complex problem, as is addiction to powerful drugs like opioids, there are many questions that doctors (and other clinicians) face. I’ve outlined below seven common questions about addiction I have regularly heard-and provide the answers. These may be of interest to you.

Q: Does making naloxone (Narcan, the drug that immediately reverses an opioid overdose) easily available encourage drug users to keep using? Is it a “moral hazard”?

A: No. People with addiction continue to use drugs (and alcohol) because they have a disease. They use to escape physical and emotional pain or to mitigate the distinctly awful state of withdrawal. They are not thinking of someone being handy with a dose of Narcan.

Q: What treatments can a doctor offer?

A: Doctors, advance practice nurses (APNs), and physician assistants (PAs) can prescribe one of three FDA-approved medications that can save lives, reduce cravings, and enable a more productive life: methadone, buprenorphine (Suboxone), and naltrexone (Vivitrol). Maintenance methadone requires a special program, so patients can’t get it in a general practitioner’s office. Prescribing is not limited to addiction experts however. Once they have a waiver from the DEA (after taking an 8-hour training), physicians, NPAs, and PAs can prescribe buprenorphine for a month as daily film tabs or give weekly or monthly subcutaneous injections. Doctors can also prescribe and administer by injection intramuscularly a monthly dose of the non-opioid (so, not addicting) naltrexone, which reduces craving for opioids and alcohol.

Q: Is that it?

A: No. As with any chronic disease, medication alone seldom does the job. For addiction, recovery groups such as Narcotics Anonymous and Alcoholics Anonymous as well as family education and support are additive in helping someone manage his or her addiction. Therapy can also be very useful, particularly cognitive behavioral therapy (CBT), which can help both with depression and in managing “triggers,” those moments when a person sees, hears, even smells something that triggers use.

Q: Many chronic pain patients are on opioids (eg, OxyContin, Percodan), some on high doses. What should doctors do?

A: Patients with addiction are seen in every doctor’s office. I would start by asking how well is the medication working in relieving their pain. Many will say, “not so well.” We know that opioids can be effective for acute but often not for chronic pain. That’s the start of the conversation. Patients, not doctors, must start believing they are not getting what they need, and that higher doses are not the answer. If the patient says, “not so well,” I would follow that by asking is it causing you problems, like constipation, sleepiness, imbalance? If it is, the patient then has told you the treatment is not working and he or she is paying a price because of the adverse effects. Your last question can be, “Do you want to try to do something about it, and if so, what might that be?” This is the clinical moment when getting off opioids and trying alternative pain management treatments becomes possible.

Q: Do you support needle exchange programs and safe injection sites?

A: Yes and yes. These are both forms of harm reduction; they keep people from contracting HIV/AIDS and hepatitis C. They keep people alive until they turn the corner into recovery, as many people eventually do-we’re just not good at predicting when.

Q: Many clinicians see recidivist patients in their emergency rooms and crisis services-opioid users who overdose or are drug-seeking. Some doctors come to resent them: after managing their overdose or refusing to write a new prescription, they’re back within days. What’s your advice?

A: That dilemma is felt by ER doctors around the country, especially in epicenters of the opioid epidemic. In many ways, these return visitors are like people with diabetes and asthma who don’t manage their illness. Our job is to help them see a different, more successful way of living. But there is one important difference with opioid addiction-the patient is in withdrawal and if that is not treated they will leave the ER seeking a fix. Some ERs prescribe a few days of buprenorphine to quiet the withdrawal so that a drug dependent person can stay away from immediate drug seeking and overdose, and perhaps even enter treatment.

Q: There’s some recent research about using the psychedelic psilocybin to treat addiction. Is that using a drug to treat a drug problem?

A: Yes and no. It is a drug, but it has no addictive properties and usually it takes only one, maybe two, psychedelic trips. In other words, it is not a maintenance “treatment,” as we use with so many chronic illnesses. The trip is a means, for some, of profoundly changing their perspective on life, of finding meaning, a sense of wonder and the universal nature of our lives. We need new and different treatments for addiction, and this is a promising one to research.

Conclusion

For a long time, doctors thought prescribing an opioid for pain was the right thing, that opioids did not have the addictive power they have. We have learned differently since then. As a profession, we now need to be part of reversing the epidemic we inadvertently helped to foster. That will and can happen every day in medical offices, clinics, emergency rooms and hospitals. And the more information the public has about what works and doesn’t work in combatting addiction, the better.

Our country has overcome many an epidemic. Doctors, nurses, and other medical professionals can be part of making that happen for today’s opioid epidemic. The sooner, the better.

Reader comment:

In his Q & A regarding opioids for chronic pain, Dr. Sederer says that when these patients come to a doctor's office, he would "start by asking how well is the medication working in relieving their pain" and he makes no mention of asking about how well they're functioning. The problem with this is that when it comes to any treatment for chronic pain including opioids, the most important question is how well the patient is functioning.  Even if the patient says he is getting excellent relief from the pain, if his functioning isn't improving, the treatment is not working. . . I think this is a very important point because many patients say they are getting relief of their pain from the opioids in order to keep being prescribed them but there is no evidence of improvement in their functioning with the drugs.
-Steven King, MD

Disclosures:

Dr Lloyd Sederer is a psychiatrist, public health doctor and medical journalist. His new book is The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs (Scribner, 2018). www.Askdrlloyd.com.