Republican U.S. senators just blocked spending $600 million dollars to help fight the drug abuse epidemic in the United States, although they joined Democrats in approving a public health bill targeting addiction.

The money would have been for increased law enforcement, prevention, treatment and recovery services for those addicted to heroin and/or opioids.

According to the National Institute on Drug Abuse, the U.S. is the largest global consumer of pain pills with almost 100 percent of the prescriptions for hydrocodone and 81 percent for oxycodone.

Research suggests that the abuse of these drugs opens the door to the use of other illegal drugs, like heroin. In addition, overdoses from illegal drugs quadrupled from 2000 to 2013, according to the Centers for Disease Control and Prevention.

Although I am all for addressing the overdose crisis in the U.S., is spending more money on law enforcement really the answer? Perhaps at the root of the problem is something simpler.

I may be the least popular person at doctors’ meetings from now on, but I’m just going to say it: Maybe doctors need to just stop prescribing so many opioids.

This is not meant to take away any of the personal responsibility that patients have in making sure that they are not abusing the system by doctor-shopping, falsifying their symptoms, or taking pills not prescribed for them.

It’s not meant to scare doctors away from prescribing the right medication dose for the right patient or diagnosis, either.

We can all do better.

300 Pills And Not Counting

Just this week I had a patient asking for Percocet. This oral medication is a combination of Tylenol and oxycodone, and is one of the strongest pain pills on the market. She said she was in pain, and her other prescribing doctor refused to give her any more.

I don’t take these requests lightly, so I went searching in her chart. In the past year, she has been prescribed more than 300 tablets of Percocet by four doctors.

First, for post-operative pain from a surgery. That’s appropriate.

Then, by her rheumatologist for joint pain. Probably justified.

However, the most recent 200 pills were prescribed by her psychiatrist for reasons unknown to me.

We in the medical profession have to start taking more responsibility for our prescribing of pain pills.

I decided to call him up and ask what was going on. It only seemed fair. He might have a good explanation. I wanted to give him the benefit of the doubt.

He responded that he only gave her one refill for post-surgery pain. When I showed him that he had actually prescribed more than 200 pills in the course of six months, he was shocked. He hadn’t looked to see how long it had been going on, or how many pills he had provided.

Many of the refills were done after a phone call request, without any office visits to document the rationale for prescribing this high dose narcotic. When I saw the patient, she seemed to be overly fatigued, complained of constipation, and also nausea — all side effects from the use of narcotics.

Now, it’s not that he’s not a smart doctor, I know for a fact that he is. But when doctors try to do patients “favors” by refilling medications out of their specialty, they are risking not only themselves, but their patients as well.

When It’s Chronic, Get A Specialist

As a board-certified internal medicine doctor, I have absolutely no experience in chronic pain management. Not once in medical school or in training have I been required to complete any type of narcotic-use tutorial. I’ve learned over the years what to do by either watching my colleagues, or by carefully treating patients.

That means I should not be prescribing chronic pain pills for patients. Yes, I said it.

And yet, each year when I have to renew my Drug Enforcement Agency license, no questions are asked about my prescribing patterns, and I have never received any feedback about whether or not I was using the medications correctly.

To my knowledge, no physicians are taught this, unless it’s their specialty, or if a lawsuit is filed, or something bad happens.

Why not? 

The best defense is a good offense here. Rather than letting just anyone prescribe narcotics, there should be a comprehensive approach and mandatory monitoring requirements for those of us who are applying to prescribe scheduled medications such as narcotics.

For the chronic use of strong narcotics, there is no regulation of how much can be prescribed, and for how long, and by whom.

This means (I’m kicked out of the lunchroom now!) that every doctor who renews their DEA license should be required to complete a certain course in the appropriate prescribing of narcotics and how to handle or refer patients who become dependent on the medicine to a certified professional.

Comprehensive pain management clinics have rules that patients and doctors follow in their prescribing of narcotic pain medications. There are urine drug tests to make sure that patients are taking what has been prescribed.

There are pain contracts, where the patient and the doctor agree to use a certain medication, agree on when refills would be made available, make accommodations for coverage when the doctor is on vacation or unavailable, and have provisions for how to revise the agreements when needed by either the doctor or the patient.

I could learn a lot from those types of doctors, and would be happy to, but let’s face it, many of my colleagues will only do it if forced to in order to renew their license.

Insurance companies can also play a key role here. I get a report on my prescribing habits from the Hawaii Medical Service Association every quarter.

Am I using formulary medications, am I overprescribing antibiotics, are patients using generics? These are just a few of the data points that I receive on a regular basis.

Since the insurance companies pay for the pills from the pharmacy, it should be easy to track. Each prescribing physician should be given a list of the narcotic medications they prescribe and for whom.

Then we can keep track, especially if one of our patients seems to be getting prescriptions from a colleague that should not be handing them out so freely, like I found out this week.

Some Pills Should Be Harder To Prescribe

The prior authorization process is another safeguard for the use of chronic pain pills. Before insurance coverage is provided, a doctor’s office should provide the medical justification for the medication, the quantity and length of expected treatment.

This process already exists for certain specialty medications, and for advanced imaging like MRIs or CT scans.

Honestly, most doctors hate it. But the fact that the inappropriate use of narcotics can lead to overdose and death seems to justify the additional work involved.

We desperately need more pain management specialists.

If prescribing doctors are certified as pain management specialists, or have additional training, then perhaps they could skip this step. For acute pain, like that resulting from injuries or surgery, certain medications should be available without any additional hassle.

But for the chronic use of strong narcotics, there is no regulation of how much can be prescribed, and for how long, and by whom. My friend the psychiatrist prescribed more than 200 pills, and if he wanted to, he could prescribe 200 more without anyone stopping him.

We in the medical profession have to start taking more responsibility for our prescribing of pain pills.

Maybe instead of spending more federal money on law enforcement, more funding could be available for better training for doctors about how to use these medications correctly.

We desperately need more pain management specialists.

For decades, there have been incentives for medical students to go into primary care in underserved areas, including loan forgiveness. Why not provide incentives to have doctors specialize in this much-needed area as well?

The epidemic of opioid abuse is certainly not going to be stopped overnight.

But a comprehensive approach is better than playing the blame game after the fact.

I, for one, am ready to learn more.