The patient had a good reason for wanting painkillers: She’d fallen off a horse about a month before, and she’d just had shoulder surgery. But Dr. Jonathan Chen, an internist at the Stanford School of Medicine, was suspicious.
The woman’s chart showed that she had recently asked her family doctor for an early refill on an opioid called Norco, supposedly because her first pill bottle had been stolen from her car. Now, she was coming to see Chen at a same-day primary care clinic where most patients had little more than a sprained ankle or a cold.
Chen looked up the patient in California’s prescription drug database, and his suspicions were confirmed. “I found that over the past two months, she had gotten 12 different prescriptions for Norco from 10 different doctors,” said Chen.
For Chen, this case was more than just a clinical challenge. It was also representative of a national problem.
In a study published Monday in the journal JAMA Internal Medicine, Chen and three colleagues found that the majority of opioid painkillers aren’t being prescribed by a small group of bad doctors. Rather, they discovered that a huge number of those drugs are coming from run-of-the-mill family doctors and general practitioners.
In a time when opioid addiction has become an epidemic, these kinds of numbers could prove important for health care professionals to understand their role in the crisis. “You can’t just blame a handful of pain doctors,” said Chen. “All of us are part of this problem whether we want to admit it or not.”
On Monday, the US Centers for Disease Control and Prevention issued new guidelines calling on primary-care physicians to closely monitor their patients’ use of opioids and to limit prescriptions to help mitigate drug abuse.
Chen’s study looked at prescriptions written by 808,020 American doctors in 2013. Because the prescribing doctor is identified by number every time a pharmacist submits a claim to be reimbursed by Medicare, the researchers could tell what specialties were prescribing the largest number of opioids.
On a doctor-by-doctor level, pain management specialists and anesthesiologists handed out the most prescriptions for opioids. On average, individual pain doctors wrote around 900 to 1,100 prescriptions for painkillers in 2013, and anesthesiologists wrote nearly 500. By comparison, each family physician only wrote about 160 prescriptions.
But because there are so many more family doctors than specialists, as a group, their number of painkiller prescriptions was higher than for any other category of health care worker, with over 15 million prescriptions collectively, followed by internal medicine physicians at just under 13 million. Together, these two groups wrote more than half of all opioid prescriptions in the country.
The next specialty on the list was nurse practitioners at about 4 million. Pain specialists, including those involved in the more invasive sub-specialty of interventional pain management, were responsible for only about 3.3 million prescriptions.
To Dr. Neil Capretto, medical director of the Gateway Rehabilitation Center in western Pennsylvania and eastern Ohio, this study confirms what he’s seen in the clinic. “At least 95 percent of the heroin users I’ve seen over the past few years started on prescription painkillers, and a lot of those people are getting it from primary care,” he said.
But Dr. Richard Dart, director of the Rocky Mountain Poison and Drug Center in Denver, worries that, by looking at Medicare numbers, the paper considers only a slice of the American population, mainly the elderly and patients with disabilities — hardly representative of the country as a whole.
What these numbers can’t show are the wrenching clinical decisions related to opioid addiction — decisions like the one that Chen faced with the woman who was going from doctor to doctor looking both to relieve her pain and to satisfy her need for Norco.
Even though he’d been gearing up to publish a paper on the topic, Chen didn’t know what to do. He told her he was worried she had become dependent on this medication, and reported his concerns to her other doctors. But he wasn’t her primary care physician, and as an internist in a same-day clinic, he couldn’t personally help her overcome her addiction. A month later, she was back at her own doctor’s office, getting more Norco.
“As a doctor, this is exactly where you get twisted insides,” Chen said. “You don’t want to see a person in pain and there’s no easy answer, which is why the discussion needs to be had at an individual level as well as a national one.”