Doctors Pressured to Prescribe Opioids to Addicts

Reimbursement patterns as well as shifts in medical pain management and in cultural attitudes toward pain help explain why doctors feel pressure to prescribe opioids even when abuse is likely.

A number of factors prod doctors to prescribe opioids even when they have good reason to believe they will be abused or diverted, according to an article by Anna Lembke, MD, an assistant professor in the department of psychiatry at Stanford University. Dr. Lembke’s perspective was published in the October 25, 2012, edition of the New England Journal of Medicine.

Dr. Lembke notes that prescription opioid abuse is an epidemic, with up to 2.4 million current opioid abusers in the United States. She points out that approximately 60% of opioids that are abused are obtained either directly or indirectly from a doctor’s prescription and that in many cases doctors are aware that patients are abusing opioids or diverting them to abusers. The question is why doctors continue to prescribe opioids under these circumstances.

The answer, Dr. Lembke explains, has to do with shifts in the philosophy of medical pain management, shifts in cultural attitudes toward suffering, and poor financial incentives for treatment of addiction compared with treatment of pain. She notes that in the 19th century, doctors were generally opposed to treating pain, which was seen as a key ingredient in the healing process. This attitude has shifted radically in the last century as opioid painkillers such as oxycodone have become widely available.

In addition, Dr. Lembke points out, patients' subjective reports of pain are given priority in treatment decisions over other potentially competing considerations such as the risk of addiction. This is in line with the general trend in medicine toward catering to patient satisfaction as measured by surveys that include questions gauging how well a patient’s pain was addressed. Doctors who refuse to prescribe opioids to patients complaining of pain are likely to receive poor scores on these surveys, not to mention poor reviews on unregulated sites such as Yelp, which can negatively impact their professional standing.

A cultural notion that “all suffering is avoidable” contributes to the pressure on doctors to prescribe opioids as does the notion that untreated pain can lead to lasting psychic damage. Reimbursement models that provide better compensation for pain management than for addiction treatment compound the problem.

Dr. Lembke emphasizes that she is not arguing against the increased attention on relieving pain, but rather pointing out that it “has had devastating consequences for patients with addiction and those who may become addicted owing to lax opioid prescribing.” To help ameliorate the situation, she proposes mandating that all physicians take a continuing education course on managing addiction that will equip them with an understanding of how it functions as an illness and with efficient strategies for curbing opioid abuse.

Dr. Lembke argues that physicians should also be legally required to check a prescription-drug monitoring database before writing an initial prescription for opioids or other controlled substances, along the lines of laws that have been passed in Tennessee and New York State. In addition, she argues that the threat of public or legal censure of physicians for failing to treat addiction must be equal to that for failing to treat pain, and that financial compensation for treating addiction must be equal to that for treating other diseases. This would require that addiction be fully accepted as a disease by the medical establishment and society and that time spent counseling patients be valued on par with writing prescriptions and performing procedures.