New pain prescribing guidelines fuel concern over legislating medical care

  • Amid an epidemic of addiction and abuse tied to powerful opioids drugs like OxyContin, shown here, the CDC is urging general doctors to try physical therapy, exercise and over-the-counter pain medications before turning to painkillers for chronic pain AP

Monitor staff
Published: 6/26/2016 12:19:42 AM

When Gov. Maggie Hassan and the attorney general’s office recommended changing the guidelines for prescribing opioids this fall, responses from New Hampshire doctors quickly poured in – and they weren’t positive.

“I just scanned this quickly, and I may be missing something, but my impression is to throw it out and start all over,” one health provider wrote on an anonymous feedback form. “This is terrible.”

“I think the AG is barking up the wrong tree six years too late,” another wrote.” It makes me think the State Police’s drug task force will come off the streets and start trolling physician offices,” another said.

“The proposed emergency rule will only make the lives of physicians more complicated, make it more difficult for legitimate pain patients to have their pain treated and push addicts to the use of IV heroin,” one doctor concluded.

Many more physicians said the timing of new prescribing guidelines was necessary, but they felt that putting too strict rules on prescribing would take away a doctor’s individual discretion in treating his or her patients. Many offered detailed, thoughtful responses on how to tailor the governor’s proposal to compromise.

With hundreds of deaths from prescription opioids, heroin and synthetic fentanyl stacking up, Hassan and the attorney general’s office didn’t mince their words when they told health providers that something had to change.

In a letter to the Board of Medicine, Hassan and the New Hampshire Attorney General’s office called board’s guidelines for prescribing narcotics “outdated” and said they weren’t transparent about the addictive nature of opioids.

Hassan had suggested that doctors require patients requesting pain medication refills to visit the office to do so, prescribe no more than a three-day supply of opioids for patients coming out of the emergency room and refer all patients who were prescribed opiates for more than 90 days to a pain management specialist.

Ultimately, the Board of Medicine passed a final version of its rules in May, trying to strike a balance between those recommendations and the concerns of doctors.

“Neither one was good for the people of New Hampshire,” said Board of Medicine president Michael Barr. Barr readily admitted that the old rules “were a little vague” and were in need of an update.

“The final rules were banged out by a lot of people with a lot of input,” Barr said.

The rules now in place include measures requiring providers to inform their patients of the risks associated with opioids, prescribe the lowest effective doses, and check the prescription drug monitoring program regularly to ensure patients aren’t doctor-shopping. The rules also state that medical providers don’t have to prescribe opioids for pain and can recommend alternatives including physical therapy and acupuncture.

And so far, they seem to have gotten better reception than the rules proposed by the governor’s office.

“It has dramatically altered the way we’re prescribing opioids to our patients,” said Dr. Gilbert Fanciullo, director of the Pain Management Center at Dartmouth-Hitchcock Medical Center in Lebanon. “We are way more conservative as far as prescribing opiates go.”

Fanciullo said he’s grateful for the new rules and the fact New Hampshire doctors are finally addressing a drug crisis that’s been decades in the making.

“It’s been going on for so long and physicians haven’t been able to do anything about it,” Fanciullo said.

Fanciullo said that while he believes doctors prescribing narcotics had the best intentions, it has gotten out of hand in many cases. For instance, he has seen patients including one woman who was on 300 milligrams of methadone per day for pain – equivalent to taking 1,200 Percocet tablets in one day.

Health and law enforcement officials agree that over-prescription of narcotics for pain sparked a heroin and opioid crisis in the nation and state. In New Hampshire last year, drugs (most of which were opiates or synthetic opioids) were responsible for 438 deaths and have killed another 141 so far this year, according to the state medical examiner’s office.

But Barr and Fanciullo say doctors’ hands were tied for many years when it came to prescribing opiates after pain was introduced as the “fifth vital sign” in the late 1990s.

For many years, pain management wasn’t just an expectation, it was mandatory. The Joint Commission on Accreditation of Healthcare Organization, which accredits hospitals, required doctors to aggressively treat pain around 2000.

Barr, a retired general surgeon who practiced in Nashua, said the directive from hospital administrators was clear: doctors and nurses must ask patients to rate their pain on a 1-10 scale, and then give them enough pain medication to treat it.

“There’s a lot of pressure not to make the patient unhappy,” Barr said. “If you send them out of your ER, then you get a bad report.”

Those patient satisfaction reports and surveys often impact how much doctors and providers are paid.

“It’s good medicine besides PR, but the other half of that is, people say, ‘I’m not going to argue,’” Barr said.

Some doctors say they think the state’s drug crisis spiraling out of control forced state legislators and medical providers to confront over-prescribing and challenge old habits.

“To the best of my knowledge, this is the first time the legislature has legislated about physician’s use of drugs,” Fanciullo said. “They got involved once they saw the number of deaths.”

Fanciullo works specifically with patients who are trying to deal with chronic pain, but the rules also apply to primary care physicians who prescribe opiates.

Dr. Greg Thesing, a family physician at Concord Hospital, said the new rules are also changing how doctors in his office prescribe opioids for pain.

“We feel like there’s a mandate from the state that we have to comply with,” he said. “Like it or not, we have to.”

While primary care providers refer patients to pain specialists if they have unique or persistent problems, they also treat pain themselves. Common patient complaints include chronic low back pain and pain related to diabetes.

Thesing said he believes the large majority of doctors feel the new rules on opioids are sound.

“Doctors in general tend not to like to be legislated to, but that doesn’t mean the recommendations aren’t good recommendations to follow,” he said.

Thesing said he thinks one of the most important rules is the one mandating physicians get extra training on managing chronic pain and the potential risks of prescribing opioids.

“Many of us weren’t as aware as we should have been in terms of the specific data and the risk of certain doses,” he said.

Barr said that doctors who keep good records and clearly document the reasons behind their medical decisions shouldn’t worry about being being overly scrutinized or targeted by the new rules.

“If you’re practicing good medicine, a lot of things in the rules make sense to practicing good medicine,” he said.

(Ella Nilsen can be reached at 369-3322, or on Twitter @ella_nilsen.)

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