Doctors` role in the prescription abuse crisis

Prescription drug “abuse” means using a controlled mind-altering substance without a prescription from a physician, or using a prescribed medication for the sole purpose of achieving a pleasurable, mind-altering effect. Medications typically abused include opioid painkillers (Vicodin, OxyContin, etc.), sedative-hypnotics (Valium, Ambien, etc.), selective serotonin reuptake inhibitors (SSRIs) and other antidepressants, and stimulants (Ritalin, Adderall, etc.). Prescription drug “misuse” refers to patients diverting controlled drugs for sale, as well as physicians prescribing a controlled drug for a patient when better pharmacological awareness or a more thorough examination would have suggested that the drug was contraindicated.

Patients use a variety of methods to obtain controlled substances illegally. These include doctor-shopping, doctor manipulation, symptom fabrication and prescription forgery, as well as certified and illegal Internet pharmacies, of which about 800,000 were estimated to exist worldwide in 2007.

As a consequence of inadequate education about addiction in medical school and residency training, a significant majority of physicians in the U.S. wittingly or unwittingly contribute to the prescription drug epidemic because they lack the skill, knowledge and training to diagnose and treat addictive disease. These deficiencies are exacerbated by prejudice against addicts, radical changes in patterns of clinical practice, substandard reimbursement, and a nihilistic attitude about treatment's efficacy.

Deadly impact

The dimension of the crisis can be visualized in this way: Currently, there are approximately 780,000 licensed physicians in the United States, with about 15,000 new graduates joining their ranks each year. A survey conducted by the National Center on Addiction and Substance Abuse (CASA) at Columbia University found that 57 percent of doctors believe it is their primary responsibility for preventing prescription drug diversion and abuse. However, two-thirds of these physicians report that they received only two hours or less of training in prescription drug diversion in medical school, residency or continuing medical education.

Moreover, CASA has reported that only one-third of physicians rated the training they received in this area as adequate. Doing the math, it is not unreasonable to conclude that at least two-thirds (520,000) of the U.S. physicians currently in practice lack the knowledge and skills to diagnose and manage addictive disease.

These undertrained physicians will thus proceed to treat the symptoms of the disease but not the disease itself. Consequently, common symptoms of addictive disease such as depression, anxiety, insomnia, migraine and other conditions tend to be treated as separate disorders, not as frequently encountered concomitants of addiction. Furthermore, many of these symptoms will be treated with controlled medications that might not be appropriate if the primary diagnosis is addictive disease. This prescribing can lead to unwitting abuse and dependence by the patient who will continue to take the medications in good faith without being aware that they may be harmful. This approach leaves the underlying addictive disease alive and undisturbed, thereby postponing indefinitely the opportunity for appropriate treatment and recovery.

Defensive prescribing of controlled drugs is also common because of fear of liability arising from allegations of undertreatment. A tragic case involved a 48-year-old patient of mine who had had a liver transplant necessitated by alcohol and other drug-related hepatitis. Although not completely abstinent, he had been doing fairly well in his recovery for three years. After he underwent outpatient surgery for a hernia repair, his surgeon, despite prior awareness of the patient's addiction and recovery, gave him a bottle of 80 Percocet tablets with instructions to take two every four hours if he woke up in the middle of the night with severe pain.

According to the patient's father, even though his son attempted to refuse the meds on the grounds that “[his] addiction would not permit him to stop at just two tablets,” the surgeon insisted that he take the bottle home. As predicted, my patient did indeed wake up in the middle of the night with severe pain and, presumably finding no relief after two tablets, swallowed the entire bottle of Percocet. His body was found the next morning.

Seeking solutions

For too long, the failure of many of the nation's leading medical education institutions to provide their students with the skills to address substance abuse disorders has been allowed to fester as a silent epidemic.

What can be done to reverse the tide? For physicians, at least, the answer lies in mandatory education and training in the diagnosis and treatment of addictive disease, including specific reference to abuse and misuse of controlled prescription drugs.

As part of its effort to reverse the prescription drug abuse and misuse epidemic in the U.S., the Betty Ford Institute in 2008 held a Critical Issues Consensus Conference entitled Addressing the Crisis: Helping Graduate Medical Education Integrate Addiction Medicine and Science Into Primary Care; The Time Has Come! The conference yielded six recommendations aimed at ensuring that core competencies and the faculty to teach them be mandatorily included in all undergraduate and graduate medical education, including examinations to assess appropriate levels of physician knowledge.

One of the conference's conclusions was that despite the fact that the core competencies for diagnosis and treatment of addictive disease have been widely endorsed by prominent medical education groups and specialty societies, the need for improved education in prescribing controlled substances in medical schools remains largely unmet.

To address this need, the Betty Ford Center, and now the Institute, since 1986 has offered residential, weeklong, innovative learning opportunities about the science and art of addiction treatment for medical students. Since its inception the program has educated more than 1,500 medical students.

In addition to education, policy and regulatory changes are also required:

• The American Board of Medical Specialties should require that knowledge in identifying, diagnosing and treating substance abuse and the prescribing/administering of controlled drugs be included in its minimum standards of competency.

• The award of Medicare reimbursement funds to medical schools providing undergraduate and post-graduate education for physicians should be contingent upon the school's ability to demonstrate that its courses follow standard curricula, and that adequately trained faculty are in place to teach them. Failure to meet this standard would lead to withdrawal of federal training funds.

• All state professional boards should require, as a condition of licensure, that physicians complete training in substance abuse, addiction, pain management and the legal regulations and responsibilities related to the prescribing and dispensing of controlled drugs.

• The Drug Enforcement Administration (DEA) should require physicians to demonstrate actual competence in prescribing controlled substances as a prerequisite for being awarded a DEA Controlled Substance Prescribing License.

• Congress should act on a variety of measures related to the prescription drug misuse and abuse epidemic by framing legislation to prohibit sale or purchase of controlled prescription drugs on the Internet and to ban direct-to-consumer (DTC) advertising for a number of mind-altering drugs.