Opioids include pills like hydrocodone and morphine are often prescribed for pain. They also include drugs of abuse such as heroin. The Centers for Disease Control and Prevention reports that more than 18,000 people died from opioid overdoses in 2014. Public initiatives from the CDC and the White House have focused on how doctors prescribe opioid pills for pain. Last week the CDC released a guideline urging doctors to show greater care and caution when prescribing opioids. Stefan Kertesz is a primary care doctor and a researcher on drug abuse. In this commentary, he shares how decisions about prescribing opioids come from delicate and deliberate conversations between doctors, nurses and patients.
“Does anyone have thoughts about Mr. Jones?” I ask around the table. My primary care team sees veterans who were recently homeless. Many have been severely injured and half have chronic pain. We have wise nurses, a committed social worker, and something else: time to focus on a vulnerable group.
And here we are today we have Mr. Jones. A bit about his case. He has a history of shoulder pain dating back to some failed surgery for fractures. I’ve changed some details to protect his confidentiality. Mr. Jones was once homeless, but he isn’t now. We prescribe opioids that another doctor started before we met him. But Mr. Jones is on high doses. And research data show that his overdose risk is somewhat higher because of that.
Mr. Jones lives in a rural community with his wife. He takes care of the garden and does all the chores. He says the pills make it possible. My team and I have looked for any hint of illicit drug use, and found none. The nurses believe he’s doing well. We’re attempting to reduce the dose, but if Mr. Jones can’t tolerate that, we won’t cut him off.
This decision is one where opioids help him live his life better, but that’s not always the case. Several new federal initiatives focus on getting doctors to rethink opioids for pain, including a new guideline from the CDC.
Now, yes, an educational word of caution is needed. There are some egregious prescribers who practically throw prescriptions at patients. And then there are many who seem to miss the realities of the people they are writing those prescriptions for.
For example, let me tell you about Mrs. Smith. We saw her last year. Oh dear. She had pain, from a badly compressed nerve. We tried many treatments, then opioids. As we earned her trust she told us about her history with substances, prescribed and not so. She told us how to get a buzz from medicine most people use for diarrhea. We stopped the opioids. We asked another doctor to see her. He prescribed suboxone, a medicine that helps with addiction. Sadly, there are not enough of those doctors. I’m still worried about Mrs. Smith.
For patients in pain, I urge treatments that don’t involve pills. I’ve dirtied my dress shirts trying to show people Pilates positions on the office floor. But I also worry that guidelines focused solely on our prescription pad fail to address the sensitive realities of pain care. In one study, the average doctor seeing a patient with pain had 6 minutes to discuss it. What will we do differently in those 6 minutes after reading the CDC’s 52-page guideline?
If all we talk about is a pill, for or against, we are having the wrong conversation. We don’t take care of prescription pads. We take care of people. New guidelines might help a little. They would help a lot if they came with commitments to assure more time for us to care for patients, and better access to specialists in addiction and pain.
Those commitments have not been forthcoming. I’m sure we can bring opioid subscribing down since it is already coming down, but to make this change humanely we need to focus on people, not just pills.
Stefan Kertesz is a physician in primary care at the University of Alabama at Birmingham School of Medicine. Views expressed represent his own opinion and do not represent positions of the U.S. Department of Veterans Affairs.