March 17, 2011 -- Statistics show the abuse of prescription painkillers has been on the rise for nearly two decades, but a new study found that primary care physicians may not be diligently monitoring patients who are taking opioid painkillers such as OxyContin, even those who are at risk for becoming dependent on them. Experts say dependence on opioids accounts for much of the rampant prescription drug abuse.
"We studied a cohort of more than 1,600 primary care patients prescribed long-term opioids and looked at how frequently they received three strategies for reducing the risk of misuse," said lead researcher Dr. Joanna Starrels, assistant professor of medicine at the Albert Einstein College of Medicine and Montefiore Medical Center in the Bronx, N.Y. The three risk-reduction strategies are urine tests, face-to-face office visits at least every six months and within a month of changing an opioid prescription, and limiting the number of early refills.
Data showed that only 8 percent of the patients in the study had any urine drug testing, less than half had regular office visits and nearly 25 percent received multiple early refills.
"This suggests that primary care physicians are not using these risk reduction strategies very frequently," said Starrels.
Whitney O'Neill knows just how powerful prescription pain medication can be, and also how easy it could be for doctors to miss the signs of addiction.
For almost eight years, she was physically dependent on them. She started taking the drugs when she was around 12, after a fall caused her to suffer from crushing migraines. She was 17 when she said the drugs became a problem.
"After years of repeated use, I developed a dependency on them," said O'Neill, now 31. "I started to get sick if I didn't take them."
While she doesn't blame her doctor for feeding her habit with a constant supply of painkillers, she doesn't think her doctor realized she had a problem. And at that time, she couldn't admit she was an addict.
"I think it was a missed opportunity to have recognized I had addictive disease," said O'Neill, who is now outreach coordinator for Faces and Voices of Recovery, an advocacy group.
Addiction specialists say a lot of burden falls on primary care physicians, usually on the front lines of pain management. Some believe primary care physicians just don't know enough about addiction, while others say factors beyond their control are contributing to the increased use of opioids.
"Most primary care physicians are not trained in addictions," said Dr. Stephen Ross, clinical director of the NYU Langone Center of Excellence on Addiction. "It's not that physicians are not well-meaning, it's just a lack of education and not knowing how to treat addictions."
"It's not a lack of awareness or caring, but they don't have the tools to help manage the risk," said Starrels. "They may not know what risk the factors are or how to monitor their patients for evidence of misuse."
As for the finding that many doctors provide more early refills to patients at higher risk for misuse, even those who have a drug use disorder, Starrels stressed it's important to figure out why. She says it may be because patients are abusing the medications or because doctors are cautious and prescribing a lower dose than patients need for pain.
"This finding is very concerning, and we need to understand the reasons."
Some Factors Beyond Doctors' Control
Other addiction specialists say it can be very difficult for doctors to monitor patients for drug abuse.
"Doctors are not detectives or mind readers and they are relatively trusting of people," said Dr. Gregory Collins, section head of the Alcohol and Drug Recovery Center at the Cleveland Clinic. "Doctors have a hard time assessing whether complaints are valid and have to rely on self-report when it comes to pain."
Patients may also hide a lot of information from their doctors, such as psychiatric medications they may be on, said Dr. Robert E. Gwyther, a primary care physician and addiction specialist as well as a professor of medicine at the University of North Carolina at Chapel Hill School of Medicine. Mixing certain psychiatric medications with opioids can have dangerous effects.
"Do they know all the drugs people are taking? Hopefully, doctors will ask," said Gwyther. Patients aren't always forthcoming about overuse or about getting painkillers from other doctors. Gwyther also said that people often get painkillers from other people, and doctors have no way of knowing about it. He believes that primary care physicians are unfairly scapegoated.
For people who have a history of abuse, those medical records may be sealed, said Collins. Doctors also don't have the time to go through a patients' entire medical chart or talk to family members about whether there's been abuse.
"Getting that kind of information out is time-consuming and frustrating," he said.
Doctors often feel a lot of pressure to treat their patients' pain. That could also lead to the over-prescribing of painkillers.
"There's an expectation that doctors are going to relieve all their pain," said Gwyther. "Doctors need to work with people to find a level of pain relief they can function with."
Although the study found that many primary care physicians don't perform urine drug tests on people who are on long-term opioids, Collins said they're not always a feasible option.
"There's a stigma attached to those tests," he said. "Also, cheating is easy, and a lot of the opiates may not even show up."
Federal Regulation Under Consideration
Five U.S. senators have introduced the Prescription Drug Abuse Prevention and Treatment Act, which among other things would encourage physician and patient education and introduce a monitoring system for prescription drugs.
"The act will make it harder for doctors to prescribe them," said Ross. "They will need a certain number of hours of education, certain licensing and it will introduce some penalties."
Gwyther says this kind of regulation isn't necessary. The problem, he believes, is much more complicated because of the factors that doctors can't control.
Addiction experts and primary care physicians agree that prescription drug abuse is a growing public health crisis, but their ideas for the best ways to address the problem vary. Some say there's a need for strategies to identify patients at high risk for abuse, others say more doctor education is needed, and still others say standards of care should change to foster a better understanding between doctors and patients.
All disagreement aside, Whitney O'Neill said she's proof that despite the continually rising tide of prescription drug dependence, there is hope.
"It's a huge misperception that people don't recover. People do recover."