Bada-Bing for Narcotics: Slapped on the Side of Our Head by the CDC

The Centers for Disease Control today released guidelines for primary care physicians for the use of the opioid medications. The guidelines are 52 pages long; they are considered voluntary (except of course to the attorneys that will utilize this information retrospectively). The guidelines are not directed towards the care of palliative care patients (broadly and appropriately defined in the document) or to the end-of-life care. These guidelines were necessary because of great variability in prescribing parameters across the country. Another horrible statistic is that over 165,000 patients overdosed on opiates during a 16-year time period. [1]

An entire generation of primary care physicians were taught that pain was the sixth vital sign. To ignore pain, you were committing negligence. Companies promoting opiates probably knew some of this information that somehow was not part of their detail to us. Every few years, we seem to get duped by the pharmaceutical industry. Several years ago it was the atypical antipsychotic medications that were safer than the horrible old first generation stuff. [2] Turns out that studies were suppressed; we were not given all of the information.

I had my first inkling that a major change was heading our way about two years ago while attending a non-profit sponsored seminar on administration of pain medications. After four hours of lectures by state experts, I said to myself that any clinician that writes for narcotics is an idiot. The tide had clearly changed. A patient that receives narcotics now needs to sign a contract (there are no standards); when they arrive at the office for their examination and review, the office can check a registry in their state (except for Missouri) to see what has been filled for the patient (in our state it is called the Arizona’s Controlled Substances Prescription Monitoring Program); and they must agree to random urine checks for substances. So much for the friendly, hand-holding experience that I signed up for.

Many physicians have just stated that they will not write for those medications at all. A patient in our wound center asked me for a referral for a new primary care physician. She showed me the letter from the practice that made two suggestions for a replacement physician for her. The fourth paragraph states:

“Please be advised that neither of these physicians will manage chronic pain as part of their practice.”

When I was winding down my outpatient primary care practice several years ago to experience another area of medicine, I remember how the number of patients that required pain medications seemed to increase in my practice. The word apparently had gotten out that I was comfortable with prescribing these medications (I am board-certified in hospice and palliative care, so yes, I am familiar on how to prescribe narcotics.) Before long, about 25% of my patient visits were related to prescriptions for narcotics. Understand me that I enjoy being a physician, but as an internist in an outpatient setting, I preferred to see the entire spectrum of adult medicine, not just one specific type of care.

© Scott Matthew Bolhack, MD, MBA, CMD, CWS, FACP, FAAP

[1] http://www.cdc.gov/media/modules/dpk/2016/dpk-pod/rr6501e1er-ebook.pdf

[2] http://www.newyorker.com/magazine/2010/12/13/the-truth-wears-off