Physicians, pharmacists & fighting addiction
The story often goes something like this: Someone sustains an injury and receives a narcotic such as hydrocodone or oxycodone from an emergency department, urgent-care center or primary-care physician's office. The prescription gets refilled over the ensuing weeks and months, during which time the patient becomes physically dependent and psychologically addicted.
The patient's physician eventually refuses to refill the medication, so the patient borrows or buys pills “off the street.” At some point, that person realizes heroin is cheaper than the pills. Once the patient turns to heroin, it is generally only a matter of time until that person overdoses and dies.
How can this be prevented? There is no single solution to prevent the opioid epidemic we as a community face. For physicians, it starts with changing the way medications are initially and subsequently prescribed. This includes recommending non-medication options such as ice, moist heat, physical therapy or alternative therapies such as spinal manipulation or acupuncture.
When a medication is necessary, it can mean prescribing alternatives to narcotics (studies show that in many instances, a non-steroidal anti-inflammatory drug such as ibuprofen works as well as, or better than, narcotics for acute pain) — or, if a narcotic is prescribed, limiting it to a small quantity. These approaches are recommended by many experts in both pain medicine and addiction medicine.
Additionally, an increasing number of insurance companies are refusing to pay for more than a five-day supply of narcotics for acute pain. Not refilling the medication after exhaustion of the initial supply is an additional strategy. Studies show that if patients are on a narcotic for longer than 30 days, the chances of them being on it at one year are over 30 percent.
As the director of the only family medicine residency in Westmoreland County, I can assure you that our doctors-in-training are learning all of these approaches.
Something that has additionally been helpful for all prescribing providers in Pennsylvania has been the implementation of the Prescription Drug Monitoring Program (PDMP) in 2016. Every time a patient fills a prescription for a controlled substance (including but not limited to narcotics), the pharmacy enters this information into a database. The PDMP requires physicians and pharmacists to review this database prior to prescribing and filling a prescription for a controlled substance. PDMPs have been shown to deter misuse and to reduce the number of narcotic prescriptions.
School-based programs are another means of prevention. Since addiction is a complex and multifaceted issue, it is difficult to quantify the effectiveness of many such programs. However, studies show school programs that address behavior, attitude and decision-making on a longitudinal basis, such as The Good Behavior Game, LifeSkills Training and Drug Abuse Resistance Education (DARE)/keepin' it REAL are effective at limiting risk-taking behavior in late adolescence and early adulthood and are superior to isolated lectures or other short-lived interventions (such as earlier iterations of DARE) that evoke a strong emotional response but do not necessarily teach a sustainable, healthy life skill. Generally speaking, it appears that school-based programs are often more effective when started in elementary and middle school as opposed to high school.
Dr. Mike Semelka is chairman of the Excela Health Department of Family Medicine and program director of Latrobe Hospital Family Medicine Residency.