Overcoming Opioids EASING AN EPIDEMIC

By CARLA K. JOHNSON

AP Medical Writer

MONROEVILLE, Pa.

Even doctors can be addicted to opioids, in a way: It’s hard to stop prescribing them.

Melissa Jones is on a mission to break doctors of their habit, and in the process try to turn the tide of the painkiller epidemic that has engulfed 2 million Americans.

It was in doctors’ offices where the epidemic began, and it’s in doctors’ offices where it must be fought. Jones is using some of the same tactics pharmaceutical sales forces used to push their potent pills into communities — this time, to get them out.

She drives 100 miles a day to visit doctors across western Pennsylvania’s Allegheny and Westmoreland counties, where prescription painkillers and their illicit cousin, heroin, killed more than 600 people last year. Bearing a smile, educational pamphlets and sometimes sandwiches, she is working to help doctors stick to new national prescribing guidelines, give them tips on how to handle patients demanding pills and remind them that opioids aren’t very good for chronic pain anyway.

“Most people trust their doctors,” said Jones’ boss, Cheryl Bartlett. “But we haven’t trained doctors about addiction, how to recognize it early and treat it in their practices. Why not help doctors better understand how to care for their patients?”

The rate of opioid prescribing has started to edge down in recent years, but it remains 56 percent higher than it was 20 years ago, enough to provide nearly every adult in America with a bottle of pills. The number of overdose deaths is still climbing, from pills that have been prescribed and from the surge of even more powerful opioids such as fentanyl on the black market, where many turn for cheaper drugs after becoming addicted.

While narcotics can bring short-term pain relief and help patients with cancer and in end-of-life care, they’re often misprescribed.

Increasingly, the fight to save lives has put doctors in the crosshairs: They often feel they have no good choices to treat pain, and not enough time with patients who are already dependent on opioids.

Pennsylvania is among about a dozen states where people like Jones try to flip the script on drug marketing and push doctors toward change. Despite mounting evidence about the dangers of opioids — and their limited benefits for chronic pain — far less is known about what works to change doctors’ behavior.

Across the U.S., lawmakers are restricting how doctors handle millions of encounters with patients in pain.

In Pennsylvania, where the opioid death rate is above the national average and rising, doctors now face sanctions if they fail to check a state-run database to flag those getting narcotics from multiple doctors. Massachusetts bars doctors from prescribing more than a seven-day supply to first-time opioid patients. Washington state won’t let doctors prescribe high doses without consulting a pain specialist. And an Illinois congressman wants all U.S. opioid prescribers to take classes every three years.

Jones uses a gentler approach. Her visits, funded by state lottery dollars, are voluntary and part of a program for low-income seniors run by the Boston-based nonprofit organization Alosa Health. Jones and her colleagues visit 2,600 Pennsylvania doctors a year to talk about opioids and other issues.

It used to be difficult for Dr. Dorothy Wilhelm, a geriatrics doctor in Monroeville outside of Pittsburgh, to get patients to agree to a urine screen to test for prescription medications and illicit drugs. Now, with new guidelines and pocket cards from Jones that help her explain the screens, patients don’t fight her anymore.

Drug companies send charismatic sales reps to visit doctors with free pens, lunches and pill samples, along with sometimes-skewed information.

In 2007, Purdue Pharma agreed to pay more than $600 million in fines for falsely informing its sales force that its opioid pill OxyContin had less potential for addiction and abuse than other painkillers. The marketing helped feed a 20-year trend of skyrocketing prescribing.

Jones, who has a nursing background, is fighting back with a charm offensive of science-backed facts.

“When I see her coming, I know I’m going to learn something and it’s fair,” said Dr. Rudy Antoncic, an internist in McKeesport.

Pain medicine emerged in the 1970s as a specialty. Many pain specialists prescribe responsibly, but others are notorious over-prescribers, handing out medicine to known addicts. Jones would rather doctors keep their patients and follow the guidelines.

Over sandwiches at a large medical practice in Monroeville recently, Jones quizzed two doctors about what’s slowing down change. Their answers boiled down to choices, time and money.

Jones reminds doctors that opioids’ side effects — besides addiction and death — include constipation and, in men, low testosterone.

Minimizing harm by getting off opioids can seem a dismal prospect to patients, unless a doctor offers other ways to cope with pain.

Many chronic pain patients with valid opioid prescriptions become addicted — the best guess is about 1 in 10, according to an analysis of 38 studies.

For patients dependent on opioids, Jones makes sure doctors know how to taper them gradually to a lower dose. A pocket card she gives them suggests starting off by cutting the dose by a quarter or a half each week, which prompts scoffs from most doctors.