Penn Study: Painkiller Prescriptions on the Rise

Do we need better options for treating patients in pain? The answer is obvious, and the solution is complicated. | DanielAzocar | DanielAzocar

Are prescription painkillers playing a role in increasing rates of addiction and overdose from prescription opioid painkillers? A study published this month in the Journal of the American Medical Association by researchers at Penn Medicine doesn’t go as far to say doctors’ pain treatment methods are the cause, but shows they have become much more lenient in recent years with prescribing opioid medications — both in larger doses and more frequently — after low-risk surgeries.

“I think much of this pattern probably derives from good intentions, says Mark Neuman, senior author of the Penn Medicine study. “It also reflects the fact that there are only so many options for patients who have pain.” The researchers say more work is needed to see how pain prescriptions plays into the addiction and overdose epidemic.

Addiction and overdose from prescription opioid medications has been on the rise over the past decade and the increase has been especially rapid in recent years. While the drug overdose death rate has more than doubled since 2000, overdoses from opioid drugs hit a record high in 2014 with a 14% increase in just one year. And Pennsylvania in particular has been hit hard by this phenomenon. Today 2.1 million people are addicted to opioid painkillers and we’ve also seen a rise in heroin addiction, which is related to opioid use.

On March 18th, the CDC issued new guidelines for physicians treating chronic pain with opioid medication and health policy experts have been trying to curtail the epidemic at the local level. Meanwhile, Congress is working on bi-partisan legislation to help prevent the increase in heroin related overdose deaths.

But how did opioid prescriptions become so lenient in the first place? Director of pain medicine and palliative care at Penn Medicine, Dr. Michael Ashburn, says that “In the ’90s, thought leaders were concerned about the under-treatment of pain.”

Doctors were concerned that their patients were suffering more than they should given the availability of treatment methods. In response to this perception, the Joint Commission, a non-profit that accredits health care organizations and programs, passed new requirements that all patients must have their pain assessed and treated. Health care organizations like hospitals or private practices started to create policies saying a patient should get treatment if they self-report a certain level of pain on a 0-10 scale. The treatment is often opioid painkillers. If the patient continues to report high levels of pain, the physician is supposed to continue providing treatment.

“The problem is that pain is not like blood pressure,” Ashburn says, “it’s an emotional experience. It’s hard for me to equate a 7 out of 10 for me to what it could be for you. Its virtually impossible for a provider to treat a number.”

Some doctors prescribe pain medications to a patient following a surgery or a painful incident, but there are also doctors, like Dr. Ashburn of Penn Medicine, who specialize in treating chronic pain when there are no surgical alternatives. Even among pain specialists, who are well aware of potential addiction, there can be an over reliance on these medications in part because of limitations on health services. Insurance companies can sometimes make it harder for people to get the holistic pain management care that they need.

“Proper care for chronic pain could involve behavioral therapy like helping people quit smoking, diet, or weight loss,” Ashburn says. “A really significant barrier is access to psychological care. No Medicaid program in Pennsylvania pays for psychological services even though Medicaid patients could benefit most from these services.”

In this way, insurance companies can make patients vulnerable to the dangers of opioid medications when they don’t cover services that could improve the root cause of a patient’s chronic pain.

Even if insurance companies do cover a certain treatment like substance abuse or psychological therapy, they often only allow patients to get treatment from a limited number of professionals who might not work in the same office as the pain management specialist. Research shows that fragmented care is typically less effective than integrated care. Penn Medicine’s pain management office is seeing an increasing number of patients with substance abuse addictions, making this aspect of treatment increasingly necessary to secure in-house.

Where do we go from here? Creating more guidelines to scale back opioid prescriptions and doses is an important step, but not the whole picture. Penn Medicine’s Neuman says that one direction research should go from here would be looking into why doctors often avoid using alternative methods like non-opioid prescriptions and regional nerve blocks. Ashburn emphasizes that part of moving forward has to involve teaching people how to store and properly dispose of their medications to prevent kids or other family members from using them. Breaking down the barriers posed by insurance coverage looks like it will be a more drawn-out battle, but its importance seems clear.

“While perhaps we’re treating pain better,” Ashburn says, “more people are dying. We have to strike a balance between compassionate effective pain care and efforts to make sure we don’t hurt our patients, our patients’ children, or their families.”