Killer Crisis: Changing prescribing behavior requires education for doctors, patients
Every opioid addiction has a starting point.
For many, that first dose comes in the form of a prescription medication.
That was the case with Dr. Angie Rake's brother. At age 26 he was prescribed the opioid painkiller Percocet while undergoing cancer treatment. His body became physically dependent on the drug, which led to addiction. The last Rake knew, her brother was living on the streets of Seattle, addicted to heroin.
"Unfortunately my brother's story is all too common," Rake said.
Beyond her family connection, Rake said she has been aware of the opioid epidemic for years as an oral and maxillofacial surgeon in the southern Twin Cities. Her speciality practice involves invasive procedures, the kind likely to require postoperative pain management.
Dentists were the top prescribers of opioids to patients ages 10-19 in 2009, accounting for about 30 percent of prescriptions dispensed, according to a study published in the Journal of the American Medical Association.
Because of dentistry's role in prescribing to teens — typically for wisdom tooth removals — Rake said she is pushing for responsible opioid prescribing. She imparts the concept on the next generation of dentists through her teaching job at the University of Minnesota School of Dentistry.
On one end of the debate are people who would prefer to keep the status quo for prescribing opioids, and on the other are those who want to stop prescribing them entirely, Rake said. She advocates for a multimodal approach that maximizes non-steroidal anti-inflammatory drugs and acetaminophen (Tylenol) before moving onto opioids.
"We are now faced with a very difficult task of predicting what level of pain a patient may experience hours after a procedure, and weigh postoperative pain relief with potential adverse outcomes," Rake said.
Before the 1990s, doctors were reluctant to prescribe opioids because of the potential for misuse and addiction, said Dr. Harold Tu, director of the Division of Oral and Maxillofacial Surgery at the U's School of Dentistry. He credits marketing by pharmaceutical companies for changing prescriber behavior and the public's perception of opioids.
Tu said he has been one of larger prescribers of opioids throughout his career. His epiphany to change came at a rally for Fed Up!, a coalition of groups pressing for federal opioid policy.
Changing prescribing behavior will require education for doctors and the community, he said. Though opioids will continue to be an integral part of treating pain, he said the shift is that other drugs can be just as effective and should be the first drug of choice.
To aid doctors and pharmacists in stemming prescription opioid abuse, the state has set up the Minnesota Prescription Monitoring Program. The database contains information on controlled substance prescriptions, including details about the recipient, quantity of medication dispensed and the name of the prescriber. All state-licensed pharmacies and providers who dispense from their office are required to report the dispensing controlled substances daily.
A goal of the program is to prevent people from getting opioid prescriptions from multiple sources at the same time.
The Minnesota Pharmacy Board administers the program. Though the board does not track individuals who are dependent on opioids, Executive Director Cody Wiberg said there is consensus among policy experts that many who abuse opioids start with prescription medication.
"That is why it is so critical to try to prevent people from abusing prescription opioids in the first place," Wiberg said.
The system appears to be catching on. In October 2017, the most recent month with data available on the Prescription Monitoring Program website, there were 111,208 database queries, up about 23 percent from the previous year.
Nate Beckman, pharmacist for Mayo Clinic Health System in Red Wing and Lake City, said it is easy to register for the program and search using the website. Providers do not have to query the database every time they write a prescription, but is a useful resource to check patient history or follow up on suspicions.
Several other states also report to the program. Information stored in the database can only be accessed by licensed prescribers, pharmacists and delegated staff.
"It is our belief that this is a critical tool and we encourage it to be used as part of patient care," said Barbara Carter, the Prescription Monitoring Program manager with the Pharmacy Board. "It gives prescribers and pharmacists one more piece of information that may identify a potential issue, confirm suspicion or even provide confirmation that the course of action the prescriber was considering is appropriate."
Rep. Dave Baker, R-Willmar, said the system is clunky and it takes three or four minutes to register a patient.
Baker, whose son died of an opioid overdose six years ago, plans to offer a bill in the state Legislature next year to charge opioid makers a fee that would be used to fight abuse, including improving the registry so it takes just 22 seconds to register a patient.
Dr. Chris Johnson of the Allina Health System, however, said doctors should be able to use the registry even if it is slow.
"I check it all the time," Johnson said. "I don't find the reason that is is cumbersome convincing. I think there is a benefit."
New state guidelines call for doctors and others who write opioid prescriptions to:
• Prescribe at the lowest effective dose and duration, no more than seven days for an initial prescription, and three days in some cases.
• Monitor patients closely while on the powerful medication.
• Work to lower addiction risks for patients on long-term therapy.
• Develop a network of other professionals, such as in mental health and pain management experts, to refer patients.