By Rose Hoban
As the number of people overdosing on opioids continues to climb in North Carolina, people who prescribe these painkillers in the state are learning how best to do that.
In part, it’s because they have to. Over the past three years, the General Assembly has passed a series of laws that will improve the state’s Controlled Substances Reporting System, a database of all prescriptions for opioids and other drugs that can be abused. The legislature has also compelled prescribers to sign up for the system and more recently has ordered providers to take a continuing education course that improves their knowledge of best practices for writing opioid prescriptions.
Most recently, the STOP Act passed by the state legislature this summer and signed into law by Gov. Roy Cooper in June sets a five-day limit on initial prescriptions for acute pain and a seven-day limit on prescriptions for post-surgical pain.
And once the Controlled Substance Reporting System is updated to make it easier for prescribers to access, they’ll be required to check the CSRS before writing each prescription in an effort to cut down on “doctor shopping” and ensure patients aren’t receiving opioids elsewhere.
But Evelyn Contre from the North Carolina Medical Board said the board has committed itself to helping people get informed.
“Their vision for the medical board is to be more of a resource for the people that we license,” Contre said at a continuing education session at Duke University on Thursday. “That has opened up a lot of doors to doing more training, to doing more creative things to be more helpful.”
Maybe not pain-free
The continuing education event, held just after work, drew about 275 practitioners, half from Duke and half from the community, to have dinner and hear a panel of speakers address topics such as managing acute and chronic pain, identifying when patients are misusing or abusing opioids, and what to about patients who have become addicted.
“Back pain is troublesome, it’s frustrating but it rarely needs opioids,” said Joey Prucha, a family physician with Duke Primary Care services. He went through a litany of research showing that other therapies from massage and acupuncture to muscle relaxers do a good job at reducing back pain.
“Superficial heat… I didn’t realize how moderate pain and disability improve at five and four days respectively, I never had realized that,” he said.
“Anything you can do to not use opioids and try to treat these people and try to educate them that it’s a slippery slope on opioids, they rarely work, and they’re not the best thing for acute pain management.”
He talked about research findings that show combinations such as acetaminophen (Tylenol ®) and ibuprofen (Advil ®) combined produced better pain relief than oxycodone alone.
“It’s pretty eye-opening,” he said.
Prucha talked about the fact that physicians need to talk frankly to patients to let them know that they may not be pain-free in an acute situation.
And he told a story about his 11-year-old son being in pain after breaking his wrist and his wife pushing the doctor at the hospital to get their son more pain medication.
“She asked for more opioids, and that resident said no. And my wife was pissed,” he said to laughter. “By the next morning – this was day four – he was fine. He was fine on ibuprofen.
“Don’t be afraid to say no when you get pushed, you will be fine. Set the expectations for the pain in terms of not being a hundred percent,” he said.
Lots of questions
The message about not being completely pain-free was part of the discussion about chronic pain too.
In the past two decades, providers have been encouraged to ask patients to rate their pain on a scale of 1 to 10, but Steve Prakken, head of the Duke Medical Pain Service, said providers have to go beyond just that number.
“The goal here is not treating the pain score,” Prakken said. “The goal here is to improve functional capacity. I tell patients, ‘I care about your pain score, but not really,’ I keep track of it, but what I care about is what you’re able to do day after day.”
Both Prucha and Prakken emphasized asking a lot of questions of patients who want more pain medication in order to help them avoid becoming dependent on the drugs.
“You want to trust everybody, but I don’t trust everybody. You actually have to verify what they’re saying,” said Prakken, who is a psychiatrist.
Prucha said he spends as long as 20 minutes just asking questions.
“My favorite question after you ask them everything else is, ‘If we did a urine drug screen, what would we find today?’ I always save that question as my very last question, after I’ve asked them all the intrusive questions already,” he said.
One point Prakken made is that more than half the overdose deaths examined in the state were people who also had other drugs – such as alcohol or depressants such as Valium – in their systems.
“Make sure that the patients know from the very beginning that you’re going to do what do you with every patient. You come in with tattoos, ear piercings and drooling, I’m going be the same with you as with grandma who walks in with a smile on her face. I’m going to do the exact same thing to everyone.”
Many more to go
Prakken also said providers should start getting used to checking the controlled substance reporting system. Once updates to the system are completed, all providers will have 30 days to sign up and start using it consistently.
There are about 30,000 physicians and another 6,500 physician assistants in North Carolina, and about 10,000 nurse practitioners. Contre said many, if not most of those providers, write prescriptions for opioids in the course of the year and those folks will need to register for the controlled substances reporting system. Everyone will need to complete the required education.
But providers have been enthusiastic, said Sara McEwen from the Governor’s Institute on Substance Abuse, which plays a role in helping develop and adopt policies around substance abuse and mental health policies.
She said that this spring, the Institute, along with the Medical Board and the North Carolina Area Health Education Centers organized four meetings in rural areas around the Piedmont: Roxboro, Henderson, Sanford and Smithfield.
“And they were still getting like 75 or 100 people there. In a place like Roxboro in the evening, that’s really difficult,” McEwen said.
“I think part of it is there’s a lot of rumors. But to hear from the horse’s mouth they come to the North Carolina Medical Board presentation, they’re going to get the real story, what is expected.”
“I’m a little confused about what I’m allowed to do in terms of narcotic prescribing, but hopefully this will clear it up,” said John Nelson, a Duke radiation oncologist.
“A lot of my patients are either in pain when I see them, or when I’m done with them, so I have to be able to control that.”
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Duke is totally wrong to leave patients in continuous pain. I went to the emergency department with a flair from some chest wall pain. I got 10 mg of oxycodone and they wanted to send me home. My pain had dropped from 9/10 to 6/10. I refused to go home until they got my pain to a manageable level. If the doctor will agree to let me drive a nail through his wrist then I’ll consider leaving in pain. It never has happened. If you have high levels of pain that your doctor won’t treat then refuse to leave the office until it gets addressed. Or make an appointment with another doctor. You have a right not to suffer. People aren’t addicts just because they don’t want to suffer.