Physicians Struggle to Manage Dual Issues of Pain and Addiction

Physicians are finding themselves caught in two dilemmas affecting them at the same time: the need to better understand treatment options for patients with opioid use disorders, and the issue of how to assist pain patients who suddenly feel shunned by the medical community.

“We pretty much have a dual crisis,” Jeffrey Gudin, MD, a senior medical adviser to Quest Diagnostics, tells Addiction Professional. Quest and the Center on Addiction today released a report that combines an analysis of drug test data and responses from a physician survey to depict a medical community struggling to address present challenges and worried about the future.

“We not only have an opioid crisis, we also have a pain crisis now,” says Gudin, who works in the Department of Anesthesiology and Pain Management at Englewood Hospital and Medical Center in New Jersey. “Doctors are so apprehensive about writing prescriptions for stronger pain medications. There is a serious need for education about appropriate use of pain medication and about substance use disorders.”

At the same time that physicians express concern about addressing the present crisis, they worry about what the next challenge may bring. Sixty-two percent of primary care physicians responding to a Harris Poll commissioned by Quest and the Center on Addiction said they fear the nation may end up trading the opioid crisis for another prescription drug crisis.

One possible culprit here, Gudin says, could be gabapentin, for which the newly issued Quest report showed a 40% increase in misuse from 2017 to 2018. Eighty-five percent of physicians in the Harris survey said they had prescribed the anticonvulsant for chronic pain in the past six months.

“We prescribed it like water,” says Gudin, who advises Quest in the areas of prescription drug monitoring and toxicology. “In order to try not to prescribe opioids, we prescribe gabapentin.” The drug is seen as generally safe when taken alone or as prescribed, but can be highly dangerous when mixed with drugs such as opioids or benzodiazepines.

Highlights of report

Quest's latest Health Trends report, titled Drug Misuse in America: Physician Perspectives and Diagnostic Insights on the Evolving Drug Crisis, combines an analysis of more than 4.4 million aggregated drug monitoring tests completed from 2011-2018 and a Harris Poll online survey of 500 primary care doctors conducted this summer.

Looking at drug monitoring results together with physician perspectives helped to illustrate some incongruities in physician attitudes and patient behavior. For example:

• While slightly more than half of drug test results from patients who were subject to prescription drug monitoring showed a sign of some drug misuse, 72% of physicians said they trusted their patients to take controlled medications as prescribed. In addition, only 55% of physicians reported discussing potential misuse of controlled substances with most of their patients who were receiving these medications.

• The Quest analysis found that drug mixing was the most common form of drug misuse, with 24% of test results showing signs of combining prescription medications with other drugs or alcohol. But a majority of physicians underestimated the extent to which drug mixing occurs in the patient population. Among Quest's findings, 17% of test results showed a dangerous combining of opioids and benzodiazepines. “As a prescribing physician I am floored by that,” Gudin says of the statistic.

At least seven of 10 primary care physicians responded affirmatively to a number of questions confirming their need for more education on opioids and addiction. Seventy-five percent said they wish they had more training on how to proceed when a patient shows signs of addiction, and 73% said they would like more information on when to refer a patient to specialty addiction treatment.

Also, 88% of physicians said they consider prescription drug monitoring, mainly in the form of clinical drug testing of patients, a critical component of practice, even though only about half acknowledge using it regularly. “It is the only objective tool to know what patients are taking,” Gudin says.