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Posted Jan 9, 2017, 12:03 pm
When Dr. Patricia Lebensohn prescribed a narcotic to a man with chronic pain years ago, she thought she had done everything right. The Tucson doctor had him sign a pain management contract to make sure he would not take any other drugs or get more pain medications from other doctors.
“I prescribed the usual,” she said. “I wasn’t excessive.”
But her patient took a bunch of his pain medication and mixed it with alcohol, she said. He overdosed and died.
That incident left an impression on Lebensohn, who wants to change the way doctors treat chronic pain in Arizona. Doctors often rely on dangerous and highly addictive narcotics to treat patients with pain, which has helped feed a nationwide epidemic that has exploded because of cultural shifts, consumer demands and poor doctor training.
She’s in charge of adding new guidelines on how to properly prescribe opioids and address chronic pain in the curriculum at the University of Arizona’s medical school in Tucson.
Many experts say doctor training is key to dealing with the national opioid epidemic.
About 72 percent of the doctors surveyed in one recent study indicated their knowledge of opioid dependence was low, and many rated their training as “unsatisfactory,” according to a 2016 study published in the Drug and Alcohol Dependence journal.
Although Arizona has developed a training program for doctors on prescribing opioids and treating chronic pain, the state does not mandate doctors take continuing education in pain management, controlled-substance prescribing or substance-abuse disorders – as several other states do. UA's College of Medicine – Tucson, the state's largest medical school that offers a doctor of medicine degree, has offered some classes in this area and it plans to add more.
In 2014, more than 14,000 people died in the U.S. from prescription opioid-related overdoses, according to the Centers for Disease Control and Prevention.
“It’s kind of sexy to talk about things like pill mills and illegal drugs coming from China, but in fact, the majority of people who get hooked on pills started out with a prescription that was totally legitimate,” said Corey Davis, an attorney for the Network for Public Health Law and author of a study evaluating continuing education for physicians.
He said something needs to change.
“If they had been teaching doctors something else that was resulting in the deaths of thousands and thousands of patients a year, they would do something to stop that immediately,” Davis said. “And the fact that they’re not doing that here, I think suggests that they don’t take it incredibly seriously.”
Pain relievers accounted for nearly 60 percent of all pills prescribed in Arizona in 2013, according to a presentation for the Bureau of Justice Assistance at the 2014 prescription drug monitoring program national meeting.
“Pain management in our country has become almost unanimous with use of narcotics,” said Mazda Shirazi, medical director of the Arizona Poison and Drug Information Center at the University of Arizona College of Pharmacy.
For a long time, many doctors believed these narcotics were safe.
A 1980 letter to the editor in the New England Journal of Medicine indicated patients would not get addicted to narcotics, so physicians started to prescribe pain medications more liberally, said Craig Norquist, an emergency physician and former president of the Arizona chapter of the American College of Emergency Physicians.
In the 1990s, many doctors thought “there’s no good reason to withhold pain medication” because they were “still under the misbelief from that article that addiction would not happen to people who had legitimate pain,” he said.
The use of opioids exploded in the late 1990s after Purdue Pharma introduced OxyContin, a strong opioid intended to treat cancer pain. An extensive marketing campaign followed, urging physicians to prescribe the drug for moderate to severe pain beyond U.S. Food and Drug Administration approval. At the same time, the public began demanding powerful narcotics. By 2001, OxyContin became the most prescribed narcotic for treating pain, according to a Government Accountability Office document.
The number of people who reported living with chronic pain also grew. Data from the 2012 National Health Interview Survey suggested that about 25.3 million American adults have daily pain.
To add to the pressure, the Joint Commission, a nonprofit organization that accredits health care organizations, told hospitals nationwide in 2001 that patients had a right to pain management.
One year later, hospitals began issuing a 27-question consumer survey that asked patients to rate how well hospital staff treated their pain.
“God forbid we get a bad (survey) score,” Amy Horton, a registered nurse at HonorHealth Scottsdale Osborn Medical Center, wrote in response to a Public Insight Network questionnaire. “Docs are afraid to say no, patients throw a fit, scream, yell, demand and give a bad Yelp review.”
People began to get hooked.
Jerome Lerner, the medical director for the pain recovery program at Sierra Tucson, said these narcotics have their place in the area of pain management. However, he said doctors prescribe them too frequently, for too long and at too high a dose.
“I have some anger that the medical community has contributed to our current opiate epidemic through our prescribing patterns,” Lerner wrote in response to the same PIN questionnaire. “I think sometimes it’s laziness and sometimes it’s lack of time that leads us to the quick and simple solution of prescribing a medication rather than dealing with the deeper and more complex issues around pain.”
The Drug Enforcement Administration has registered about 24,000 practitioners and 9,000 mid-level practitioners who can prescribe narcotics in Arizona. These numbers include physicians, nurse practitioners, physician assistants, dentists and veterinarians in the state.
The U.S. government rates opioid medications as Schedule II, meaning they are highly addictive and dangerous. Although prescribers must register, it is ultimately up to the practitioner whether to prescribe narcotics, according to the DEA.
Davis’ research referenced many studies that showed doctors rated their training as poor or unsatisfactory. Many doctors said they did not receive proper education in medical school to properly prescribe opioids or treat addiction.
“I was most definitely not properly prepared in medical school for that,” said Dr. Scott Steingard, a family practitioner for Steingard Medical Group in Phoenix and former president of the Arizona Board of Osteopathic Examiners. “But when I finished in medical school, the use of opioids was a relatively uncommon event. Now I believe there has to be a more formal process in the medical schools to properly teach the use and misuse of opioids.”
The University of Arizona College of Medicine has been teaching students about narcotics and pain management during their first two years. One professor estimates that students spend six hours learning about chronic pain management in the classroom, but the school plans to increase classroom training related to opioid prescribing. During their last two years, students spend most of their time in the clinical setting, how much they learn depends on the patients they receive.
The A.T. Still University of School of Osteopathic Medicine in Arizona teaches students to treat pain in many courses, according to the course catalog. The school does not offer classes specifically on pain management for doctor of osteopathic medicine students.
The College of Pharmacy at Midwestern University – Glendale has several health care programs, including dental, osteopathic and veterinary medicine. Each of the six colleges incorporate some pain management training into its curriculum, according to the course catalog.
In the College of Pharmacy, students are introduced to pain management early in their first year starting with over-the-counter medications. Professor Mindy Burnworth teaches second-year pharmacy students how to appropriately dose, manage and monitor opioid analgesics during the pain management segment of a required course. The lectures are supplemented with workshops where students role play to practice what they learned.
Pharmacists play an important role in the distribution of prescription medication, she said, acting as a second gateway for informing patients of possible side effects, such as addiction, and medical interactions to avoid, including mixing opioids with alcohol or benzodiazepines.
The College of Pharmacy students get a lot of practice before they graduate, training with real patients in various pharmacy settings during their final year. By the time students graduate, they know a lot, but not everything, Burnworth said.
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“I feel we have armed our students with the foundational knowledge that they need,” Burnworth said. “But through their career, they will always need to continue building on their education.”
Even when they do get proper training in medical school or later, doctors struggle with the balance between identifying people who need the drugs to cope with pain and those who abuse them.
“Every doctor worries about the misuse of opioids,” Steingard said. “Do we have bad actors come into our practices that would like to abuse opioids? Absolutely.”
That doesn’t mean doctors should stop prescribing opioids, because some patients have a legitimate need for them, he said.
There is now a system to help doctors identify those “bad actors,” Steingard said. A law, passed earlier this year, requires doctors to look up patients in the Controlled Substances Prescription Monitoring Program database before prescribing a controlled substance.
Steingard said he did not receive enough education in medical school to properly prescribe opioids, but he learned through attending professional seminars, talking with other doctors and taking continuing medical education.
Once doctors graduate medical school, they must take 40 hours of continuing medical education every two years before the Arizona Medical Board or the Arizona Board of Osteopathic Examiners will renew their license.
However, the doctors choose the courses.
In Davis’ study, the author suggested that “many primary care providers hold incorrect beliefs about basic facts regarding opioid painkillers.”
He suggested a fix: Require all Arizona doctors to take courses and learn how to manage chronic pain without opioids, how to treat people with substance abuse disorders and how to properly prescribe opioids when needed.
Ideally, he said, they would learn about these issues during medical school or while doing residency or fellowships.
“At some point, they should have to demonstrate that they’ve received education, or even better, they should be required to demonstrate some kind of efficacy,” he said.
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He also suggested the state require practicing doctors to take continuing medical education courses. Only five states require all or nearly all doctors to periodically take continuing medical education in pain management, substance use disorders or controlled substance prescribing, including Iowa, South Carolina and Tennessee. However, 23 states require at least some physicians – often pain clinic practitioners or controlled-substance prescribers – to receive such training at least once, according to the study.
Norquist supports more education, but said he opposes such a mandate.
“There are a lot of people who feel like they should mandate, regulate or basically control the way I practice medicine,” he said. “Maybe we have that coming, because we haven’t done the greatest job with it over time. Maybe a little bit of criticism is in order, but then to start passing laws to say that you can’t do this until you do that, is a bit extreme.”
The Office of Continuing Medical Education at the University of Arizona College of Medicine – Tucson has worked with Dr. Dan Derksen in the College of Public Health to develop an online course on how to prescribe opioids and deal with chronic back pain. Officials have offered the free course since 2015, but only about 500 prescribers have registered to take it.
“That’s a pretty good number of physicians taking the course on their own volition,” said Randa Kutob, the director of the office of Continuing Medical Education at the University of Arizona who was involved in developing this course. “In general, physicians want to be educated on the topic because they’ve heard about the adverse outcomes, and they want to know how to keep the patients safe.”
An Arizona Department of Health Services grant helped fund the course.
Robert Amend, an operations manager at the office of Continuing Medical Education, said although he’s “fairly pleased” with registration for the course, he would like to see 100 percent of doctors take it.
“People don’t take stuff unless it’s mandated, to be quite honest with you,” he said. “(Otherwise), they’ll do everything they can to avoid it.”
The Arizona Board of Osteopathic Examiners regulates and licenses more than 3,200 doctors of osteopathic medicine, and its members have not discussed mandating doctors to take opioid related continuing medical education, said the executive director, Jenna Jones. Members of the Arizona Medical Board did not respond to requests for comment.
Additional educational efforts
Instead of a mandate, Norquist said he prefers educational materials spread in a more organic way.
About eight years ago, Norquist helped spread chronic pain guidelines developed at his hospital to other facilities across Arizona through outreach efforts and by word of mouth.
“These chronic pain guidelines gave us something to stand behind when we refused to write pain medicine for the patients that kept coming back,” he said. “They also gave us a resource for those patients who needed chronic pain assistance, as well as those who needed help with addiction.”
The guidelines suggest doctors refer patients who frequently visit the emergency department to a pain management clinic and primary care doctor so they can receive more consistent treatment, he said.
There are many other efforts going on in Arizona to educate prescribers.
The University of Arizona College of Medicine – Tucson is one of 60 universities across the nation that agreed in March to require students to take prescriber education along the CDC guidelines for prescribing opioids for pain.
Lebensohn, who is in charge of adding the guidelines to the UA medical school curriculum, said the students will learn when pain medication is needed, how to start patients on pain medication, draft pain contracts, mix medications, use the CDC’s guidelines to manage chronic pain patients and ultimately wean patients off narcotics.
She also plans to add alternatives to medication, like acupuncture and mind and body practices like yoga, chiropractors, meditation and massage therapy to the curriculum.
“I have personal experience of the danger of being on a chronic narcotic medication, so I take this very seriously,” Lebensohn said. “There are so many other options to treat chronic pain that a lot of the time physicians don’t know enough about it.”
Correction: An earlier version of this story contained inaccurate information about Arizona medical schools that offer doctor of medicine degrees. Both the University of Arizona College of Medicine – Tucson and the University of Arizona College of Medicine – Phoenix offer such degrees.