How Medical Professionals Can Fix Opioid Overprescribing
SCOTT SIMON, HOST:
Doctors, surgeons and dentists are still overprescribing opioid medications, often ignoring federal safety guidelines. Critics say that puts millions of patients at risk. NPR's addiction correspondent, Brian Mann, joins us. Brian, thanks so much for being with us.
BRIAN MANN, BYLINE: Hi, Scott.
SIMON: And your reporting has found that even after a decade of deaths and a lot of public concern and even outrage, huge numbers of prescriptions are still being written. Why is that?
MANN: You know, this is really confusing, Scott. And for a lot of critics, it's infuriating. A bunch of new research we looked at found clinicians giving out a lot of these pills to people for really minor conditions - things like lower back pain, ankle sprains, routine tooth extractions. And a lot of it seems to come down to the culture of American medicine. For a generation, even good, ethical doctors were trained to treat pain really aggressively using these opioids. Laura Burke (ph) is an emergency room doctor we talked to in Massachusetts who told us she still struggles with how to help patients in pain.
LAURA BURKE: I like to try and avoid opioids. But if they feel like it is the right thing for them in that moment, when they understand what they're feeling and what they're going through, sometimes, I feel, who am I to necessarily deprive them of something that can alleviate their suffering?
MANN: And people who study opioid prescribing say this attitude is still deeply ingrained. And it's really different from the way health providers think in other countries. One new study found American dentists, for example, are still giving out opioids at rates 70 times higher than dentists in Britain.
SIMON: Seventy times - that's extraordinary. And I know you found people who were talking about ways to fix this. What are some of the best ideas you heard?
MANN: Well, it's important to say that there has been progress already. Prescribing is still twice what it was before the opioid boom began, but it's down from peak levels. That's in part due to tighter regulations and just better medical practice by doctors like Laura Burke. Another reform people are talking about now is trying to fix health insurance. In much of the country, insurance pays for opioids, but it doesn't cover alternatives like physical therapy. Jody Glance is an addiction expert at the University of Pittsburgh we talked to. She says our health-care-fee structure also often incentivizes doctors and patients to choose opioids.
JODY GLANCE: A lot of times, you know, the copays are per visit. So if you're talking about the copay for a medication that lasts you 30 days versus the copay for a three-time-a-week physical therapy, you know, you're talking about financial concerns.
MANN: And changing that is hard. This month, Colorado Governor Jared Polis vetoed a bill that would've required insurance companies to pay for pain treatments other than opioids. He said it would be too expensive for companies and would force them to raise premiums. Other reforms, though, seem a lot simpler and cheaper. And it's unclear why they haven't been adopted more widely. For example, one researcher we talked to, Katie Suda, found dentists could reduce risks to their patients simply by giving them weaker opioids.
KATIE SUDA: If we replace every oxycodone prescription with a lower-potency opioid, overprescribing would decrease by over 20%.
MANN: So dentists, for example, might use codeine instead, which is what dentists generally do in Europe. Another fix involves the electronic prompts on medical smart devices. This is interesting. Surgeons give out millions of these unneeded opioid pills every year. But one study found if you just change the options on their pop-up screens, they prescribe fewer doses. Keith Humphreys studies prescribing at Stanford University.
KEITH HUMPHREYS: Surgeon will go on the record, and they'll have maybe 28 pills. And you just click a box. And it's 28 but there's nothing magic about 28 pills. And there's some nice studies showing that if you change that number, and you, say, make it 12 pills, a large number of physicians then pick 12. It's a little scary.
MANN: Scary because it shows how quickly and sort of reflexively many clinicians make these decisions. And with a little more guidance, experts think they might choose fewer pills every time they're with a patient.
SIMON: Brian, obviously, those fixes are aimed at new patients. What about the millions of Americans now who already take medical opioids? Some of them have been dependent on them for years.
MANN: Yeah. Well, first, let me say, Scott, that in some cases the medical literature is clear that opioids are the best option for some kinds of pain. But the researchers we talked to say a lot of these prescriptions are going to people not just because they're in pain but also because they're physically dependent. Here's Keith Humphreys again. He says a lot of those patients are just stuck.
HUMPHREYS: And they've been on it for, you know, 15 years. And they shouldn't be on it, but they are on it, right? And that doesn't - the fact that maybe they never should've been put on this dose in the first place doesn't mean if you take it away, they'll be better. They could crash, and, you know, experience horrible withdrawal or make a suicidal attempt. You have to manage that legacy.
MANN: So there are no really easy answers to this part. These opioids have serious side effects, but many doctors don't have the training to wean patients off them safely. So for now, millions of Americans caught up in the medical opioid boom - the experts we talked to say these prescriptions may actually be their best option.
SIMON: Brian Mann, NPR's addiction correspondent, thanks so much.
MANN: Thank you, Scott.
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