Imagine you’re a doctor facing a patient who has tried a host of different medications to treat his severe back pain. “Doctor,” he tells you, “nothing is working and I’m still in agony. I can’t work. I can’t sleep. You have to help me.”
Among the few options left to you is an opioid painkiller, such as morphine. You want to help your patient, but you’re caught in a dilemma: Opioids are not right for everyone, and they run the risk of addiction. But if you don’t prescribe them and your patient really needs them, he’ll suffer.
Finding the right alternative, or deciding if morphine is the right choice, can be tricky. You didn’t get enough training on the topic in medical school. And if you do prescribe the morphine, time-consuming paperwork (with added potential for error) now awaits you, under new insurance regulations that just came into effect this week.
This type of scenario concerns Dr. Dan Alford. He teaches at Boston University School of Medicine and directs the state program that trains doctors in how to safely handle the complexities of prescribing painkillers.
Opioid painkillers such as morphine, codeine, methadone and oxycodone are a complicated family of drugs that pose a serious addiction risk for many people. The state's largest insurer, Blue Cross Blue Shield of Massachusetts is aiming to curb those risks with new regulations that tighten control on access to these drugs.
The rules, which took effect Sunday, encourage patients to seek alternatives before asking for opioids, and, in theory, make it harder for doctors to overprescribe the drugs.
The rules aim to reduce addiction, but Alford and many of his colleagues are concerned that the blanket changes may create another risk: under-medication. With more hoops to jump through, he said, many patients who are truly in need of prescriptions may not be able to get them. At the same time, doctors wading through paperwork may be more likely to slip up or prescribe the wrong thing just to avoid bureaucracy.
So Alford, who practices at Boston Medical Center, is spearheading an effort to train doctors and their staff in how to deal with the new regulations. But he’s quick to note that this isn’t about simply making the drugs more freely available. Rather, it’s an effort to recognize how complex these opioids are, make sure patients understand the alternatives and, if necessary, ensure patients who do need opioids are able to get them.
“To actually regulate the practice of medicine by creating authorizations and other laws...insurance companies making those statements, it makes it harder to practice medicine,” Alford said in a recent telephone interview. “I certainly understand their intentions, i just feel like the unintended consequences aren’t being appreciated.”
Alford’s training program aims to help doctors understand how to approach scenarios he said they don’t come across in medical school — situations involving patients who say they’ve tried every other option, nothing’s worked and they’re suffering, or patients who want to transfer a prescription from another state where the regulations are different.
“Those are common scenarios and the person who’s writing the script is not well trained to do it, but they can’t put it off,” Alford said.
Alford described the tenets of the training program in a recent essay:
Communication between doctor and patient is key. The conversation is complicated and
uncomfortable when a clinician is convinced the patient is addicted, while the patient is sure their
terrible pain only needs higher opioid doses. How to have these conversations, and make the
appropriate determination about medication, is not taught in medical school.
Physicians who are experts in pain management have developed guidelines for safe opioid prescribing. These include such clinical tools as requiring patients to sign pain treatment agreements that outline opioid medication benefits and risks. Drug testing and pill counts are recommended to ensure that patients are taking the medication and not giving it to friends and family or selling it. Physicians can use an on-line state prescription monitoring program to monitor patients’ prescription history and identify those who are “doctor shopping” — getting opioids from different physicians.
The program puts a big emphasis on covering all the appropriate bases when it comes to prescribing; Alford said doctors can often end up writing prescriptions without having the appropriate conversations with the patients, concerning risks and benefits or alternatives.
“Nowhere else in medicine is there an area where you’re being asked something you’re really not trained to do when there are so many unappreciated consequences to do it,” he said. And added bureaucracy, he said, will only hinder the process more. “It’s not a big deal to write this one authorization, but when you add it on to everyone else…you’ve got a mailbox full of forms that need to be filled out for more and more things,” he said.
That added bureaucracy, he said, makes medication more expensive and harder to access because of concerns about addiction, which are valid. Insurance companies, he said, want patients to try every other option first. But sometimes opioids are the right medication for a patient, and Alford’s training aims to better educate doctors to make those tough calls. “There’s not enough emphasis put on education and training. There’s just emphasis put on regulations that minimize the number of prescriptions they can write,” he said. “That’s going to solve the overprescribing problem, but it’s certainly not going to solve under-prescribing or the effective prescribing, getting the opioids to the right patients at the right times.”
And what can patients do? Alford stressed that patients, too, must understand that opioid painkillers are not a magic bullet – and that the patient is ultimately responsible for the security and safe use of their medication, whatever it may be.
This program aired on July 5, 2012. The audio for this program is not available.