Want a New Year’s resolution? Prescribe fewer painkillers

If you’re looking for a New Year’s resolution for 2016, you may want to consider prescribing your patients fewer opioid painkillers – or at least consider considering it. It’s not just a few rogue doctors playing Dr. Feelgood that are singlehandedly fueling the narcotic painkiller epidemic in the United States.

According to a new study from the Stanford University School of Medicine, it does not simply come down to Dr. Doom and Dr. Evil, but it’s actually a veritable Dr. Who’s Who of specialists across all fields of medicine who generate millions of opioid prescriptions – including family practices (15.3 million prescriptions), internal medicine (12.8 million), nurse practitioners (4.1 million), and by physician assistants (3.1 million). “The bulk of opioid prescriptions are distributed by the large population of general practitioners,” study author and instructor of medicine and Stanford Health Policy VA Medical Informatics Fellow Dr. Jonathan Chen said in a press release. “Being a physician myself, I am acutely aware of the emotional angst that can occur when deciding whether to prescribe opioids to a patient who may have simultaneously developed a chronic pain and substance-dependence problem. The public health epidemic of opioid overuse is perhaps not surprising given the tenfold increase in volume over the past 20 years.”

Chen and colleagues found that the top 10% of opioid prescribers accounted for 57% of opioid prescriptions and 63% of all types of drug prescriptions. This pattern reflects Medicare data for prescribers of all drugs; the top 10% of all drug prescribers account for 63% of all drug prescriptions. The Stanford study used a different set of data that previous research and likewise arrive at different conclusions. For example, instead of using California workers' compensation prescriptions – as did a 2011 California Workers' Compensation Institute study which found that 1% of prescribers accounted for one-third of opioid prescriptions, and that the top 10% accounted for 80% of prescriptions – Chen and his team used all Medicare prescription drug claims made in the 2013. “This data set indicates no special distinctions in the concentration of opioid prescribing among Medicare prescribers,” Chen said. “The earlier study suggests potentially aberrant behavior among those extreme outlier prescribers, while implying the remaining majority do not contribute much to the problem -- and now we know this is not the case.”

The authors of the new study attribute the difference between their findings and those of previous ones (which suggested that a small number of prolifically prescribing specialists running ‘pill mills’ was behind the opioid epidemic) to the fact that the Medicare population is more generally representative of the population at large – as opposed to, say, the California Workers' Compensation data and the characteristics of that specific population, which may have a greater prevalence of multiple illnesses or employment in jobs more prone to injury. “These findings indicate law enforcement efforts to shut down pill-mill prescribers are insufficient to address the widespread overprescribing of opioids,” Chen said. “Efforts to curtail national opioid overprescribing must address a broad swath of prescribers to be effective.” Narcotic painkillers have become a source of concern because they are designed to reduce the intensity of pain signals that reach the brain, but also have the potential of being highly addictive; unlike other approaches that many doctors seem oblivious too, such as TENS unit supplies which target pain without the side effects of opioid drugs.

In summary, we can safely say that no doctor is an island and the combine actions of all physicians can achieve the opposite result of your individual actions. Thus, even if you are satisfied with your narcotic prescription volume, that doesn’t mean you should wash your hands of the whole thing. As a doctor it is part of your responsibilities to work toward the greater good of your patients and other doctor’s patients and other doctors. Therefore and in addition to – or in lieu of – prescribing fewer opioid painkillers and offering alternative approaches to pain management, you can devote some of your time during this new year 2016 to raising awareness of the prescription narcotic epidemic among your fellow physicians. 

Related: America’s Opioid Crisis: Are you part of the solution?