Oregon doctors prescribing opioids more cautiously

By Elizabeth Hayes, Portland Business Journal, Sept. 30, 2013
Abuse of prescription drugs like Oxycontin has skyrocketed in recent years.

Abuse of prescription drugs like Oxycontin has skyrocketed in recent years.

It’s no secret that abuse of both prescription opioids and heroin has been skyrocketing across the U.S. and in Oregon, which has the highest rate of prescription drug misuse in the country.

The Obama Administration has labeled opioid abuse a national epidemic and that sense of urgency can be felt at the state and local levels as well.

“One thing we’re hoping to decrease is the high rate of overdoses,” said Melissa Weimer, assistant professor of medicine at Oregon Health & Science University and medical director of CODA, Inc., a Portland substance abuse treatment center.

A multi-pronged approach is unfolding:

  • Oregon is part of the National Governors’ Association Task Force on Prescription Drug Misuse, which is working to reduce the number of pills in circulation and to educate patients, prescribers and the public about the long-term effects and risks.
  • OHSU is organizing periodic educational events for physicians and other professionals.
  • The Public Health Authority has a prescription drug monitoring program in which pharmacies report every opiate prescribed, so they can be tracked in a database that physicians can use to make sure a patient isn’t getting the same prescription from four different doctors.
  • OHSU, Providence Health & Services, Legacy Health and other hospitals have informally developed community standards for prescribing opiates, said former Multnomah County Health Officer Gary Oxman. Every health system has adopted its own guidelines and dose restrictions, but they are similar.

“They’re trying to approach it primarily through cutting back on prescription opiates and developing standards to help do that,” Oxman said. “They’re much less inclined to give opiates and dosages are more controlled.”

Weimer said there’s more of a focus on safety and efficacy, and some doctors have created chronic opioid agreements with patients that require them to do pill counts; to not call for refills at night, on weekends or holidays; to not use another person’s medications or illegal drugs; and to consent to random drug screenings.

“We’re not saying opioids are evil, but we need to prescribe them in a safe way and let patients know what the risks are for safe and effective use,” Weimer said. “Nobody wants to be that clinic in Portland that’s higher.” But she noted that some prescribing practices are “pretty entrenched.”

Kaiser Permanente Northwest is also trying to limit the number of pills a patient gets in a prescription, said Dr. Ellen Singer, chief of internal medicine. The push now is to start patients with just a small amount of pain medication and make sure there’s no risk of substance abuse and look at other ways to manage pain and treat depression, Singer said. The strategy seems to be working. Morphine-equivalent dosing has decreased 45 percent since 2009 at Kaiser.

She said doctors increasingly are tracking patient opioid medication data, and physicians are receiving training in how to deal with angry patients when they don’t get as much pain medication as they’d like.

“These patients can be very threatening,” Singer said. “It’s hard when somebody comes to you who’s been on crazy doses of medication. Patients can play you.”

Oxman said it’s also important to make sure patients who are prescribed opiates are evaluated for substance abuse and mental health disorders and that doctors send prescriptions to a single pharmacy in order to keep better track.

“Part of what needs to happen in the future is integrating behavioral health and substance abuse screening into primary care,” said Lisa Millet, injury and violence prevention section manager for the Oregon Health Authority. That’s happening currently with the Coordinated Care Organizations, which deliver care to Medicaid patients.

In addition to refining prescribing practices and increasing education, more needs to be done to address addiction, Weimer said.

“There needs to be more access for patients to get treatment,” Weimer said. “We need to get them somewhere where they can get detox. It involves resources that are scarce.”

Editors note: The price of addiction is an ongoing series looking at how prescription painkiller and heroin addiction is affecting Portland. Later this week, a look at treatment options in Portland.