According to the Centers for Disease Control (CDC), enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for a month. Although most of these pills were prescribed for a medical purpose, many ended up in the hands of people who misused or abused them.
The Centers for Disease Control (CDC), the Office of National Drug Control Policy (ONDCP), the Drug Enforcement Administration (DEA), the Food and Drug Administration (FDA) and the United States Congress have identified that we are in the midst of an epidemic (defined as “affecting or tending to affect a disproportionately large number of individuals within a population, community or region at the same time”) of prescription drug misuse, dependence and overdose. According to the CDC, deaths from prescription painkillers have reached epidemic levels in the past decade. The number of overdose deaths is now greater than deaths from heroin and cocaine overdoses combined. A big part of the problem is nonmedical use of prescription painkillers—using drugs without a prescription, or using drugs just for the “high” they cause. In 2010, about 12 million Americans (age 12 or older) reported non-medical use of prescription painkillers in the past year.
Improving the way prescription painkillers are prescribed can reduce the number of people who misuse, abuse or overdose from these powerful drugs, while making sure patients have access to safe, effective treatment. It is estimated that approximately 76 million Americans suffer from chronic pain and many of these people become addicted to opioids. As I travel around the country lecturing about chronic pain and addiction, I am always asked questions such as these:
- Why do doctors prescribe so much medication?
- Why don’t doctors warn their patients about the long-term effects of opioids, including tolerance and physical dependence?
- Why do doctors keep prescribing, even when my client is showing signs of decreased function and addiction?
- What can I do in such a situation?
I hear complaints about doctors prescribing medications to clients who are in substance abuse treatment programs. “Mr. Jones was on 24 medications. What can we do about doctors who prescribe so many medications? I can’t call the doctor—I’m only a social worker/counselor/marriage and family therapist, and the doctor won’t listen to me.”
Clinicians are frustrated with a sense of powerlessness to impact a pain management system based on prescribing habit-forming medications. I’m told “All these clinics care about is money!” and “Doctors don’t understand addiction!” and “Changing the system is impossible!”
My response starts with a challenge: How would you work with a client who presented with such a dilemma? Let’s look at what’s been done so far:
- Have you spoken with the prescriber?
- Have you ever met or asked to meet with the prescriber?
It is unreasonable to believe that all doctors are unapproachable or uninterested in hearing from you. Many will be grateful to know that you are working with their client. Offer yourself as a resource to the doctor. Ask if they have concerns about the client’s medication use; often they will admit that they do have concerns and that they are clueless as to how to proceed. Of course, send a signed release from your client, perhaps with a note asking if you might arrange a time to call, before attempting to contact the practitioner.
Anticipate that most prescribers want to do the right thing. Many are ill-equipped to have a conversation about the risks and benefits of opioid medications, let alone instructing a client on coming off medications. It is common knowledge that it takes 5 minutes to say “yes” and 45 minutes to say “no” when it comes to prescribing medications.
Saying no often leads to a conflict ridden conversation. You can be the facilitator of progress in the process of helping a doctor to impact their client’s behavior, through techniques including cognitive behavioral therapies, motivational interviewing and others.
If the doctor will not discuss the case with you or, worse still, won’t call you back—what then? Do you simply give up? Would that be your advice to your client who was up against such an obstacle?
A lot depends on the system you are a part of: is there a way to get to the doctor? Perhaps schedule an appointment to visit the clinic. Get to know the doctor’s office staff or colleagues. Send a letter of introduction to a specific person who might get it to the doctor. Does the doctor have a supervisor? If you are having a problem, you won’t be the only one. If the doctor won’t respond to you, how must it be for your client?
Talk to your client. If he or she wants help getting off medications, then give him or her suggestions about how to represent him / herself with the doctor. Teach clients to advocate for themselves. Offer to rehearse conversations with the doctor. Enlist the help of family, if any, to assist the client.
Doctors need help with this epidemic. Many don’t have the skills to work effectively with our clients. Addiction Counselors are in the perfect position to help. You are well trained in motivating clients who are ambivalent about changing. Let’s utilize those same skills in our communities to motivate prescribers! You may find that the doctor will be pleased to know that the patient is working with you in your clinical practice and will be willing and grateful to collaborate.
To my physician colleagues who are reading this: I know I’m preaching to the choir. I believe it is our responsibility as educated, responsible addiction professionals to be readily available to assist our peers and colleagues on the difficult treatment issues that are facing prescribers when treating chronic pain. We might also assist the counselors we work with in their interactions with prescribers about these issues.
What are the alternatives? Prescriptions get written; clients develop dependence and overdose rates continue to rise. This is unacceptable. Furthermore, many of your clients are taking opioid and sedative medications because the drugs have been prescribed. Your job as a counselor includes advising clients on how to assess whether or not these medications are helping or, in fact, making life worse. If function is decreasing while on the drugs, despite some minimal pain relief, the better course for your client may be to wean off or discontinue these medications and find alternative ways to deal with the pain, including the cultivation of mind, body and spiritual techniques. If this conclusion is reached, these clients will need your support and encouragement through the difficult transition while their prescribers are likely to appreciate the support that you will be providing.
This blog post was written by Mel Pohl, MD, FASAM, author of the book, A Day Without Pain (Revised)
