Editor’s Note: Physicians treating opioid-addicted patients have a unique perspective on the problems arising from the dramatic increase in the prescribing of opioid medication. Dr. Andrew Kolodny has used this perspective to create a public initiative that works to re-establish a better balance in using these important medications to relieve pain while reducing some of the problems that have emerged from their recent excessive use. His leadership has in this area has helped to bring attention to this national problem.
“Initially many in the medical community believed that concerns about opioid addiction were overblown,” said Andrew Kolodny, MD, of Phoenix House, which provides individualized, holistic drug and alcohol addiction treatment.
“In their minds, the proper way to treat pain was with opioids,” he continued. “Many people were taught this, believed it, and were teaching it to others.”
Increases in deaths due to opioid overdose as well as concerns about how the medical community viewed the prescription of opioids led to Kolodny and several other physicians to found Physicians for Responsible Opioid Prescribing (PROP). He serves as the organization’s executive director.
A significant part of the group’s efforts has focused on re-educating their peers about the dangers of overprescribing opioids. “They were being taught to put people on round the clock opioids, so they wouldn’t have to experience pain,” Kolodny said.
However, by doing this, he said doctors have “made the individual physiologically dependent on the drug. As a result, the patient develops a tolerance to the pain-relieving effect of the prescribed opioid and requires higher and higher dosages.”
According to Kolodny, these medical practices have contributed considerably to the country’s opioid addiction epidemic: “Many Americans are truly convinced that opioids are helping them. They can’t get out of the bed without them.”
Kolodny talked with Modern Addiction Recovery about PROP’s ongoing efforts to decrease overprescribing of opioids, and ultimately deaths from overdose.
Modern Addiction Recovery: How did you get involved with Physicians for Responsible Opioid Prescribing (PROP)?
Kolodny: PROP was formed about five years ago. The founding members were from different medical specialties, including primary care, emergency medicine, pain management, and rheumatology. We shared a common concern about the medical community’s overprescribing of pain killers and how this was contributing to opioid addiction and overdose. We all felt frustrated because policymakers could make interventions, but they weren’t making them because the conversation had been dominated by organizations and individuals that receive funding from companies that produce opioids, who told them all of the good things about the medicines.
Policymakers were told by industry-funded pain organizations not to penalize pain patients because of drug abusers. We realized that this wasn’t true. We don’t have these two distinct groups, one for pain patients and the other for drug abusers. The opioid crisis is about addiction, and the reason that overdose deaths are at historically high levels and the death rate for middle-aged white Americans is going up is due in large part to the epidemic of opioid addiction with overdose deaths occurring most commonly in people with legitimate prescriptions.
MAR: How did the medical community respond to PROP?
Kolodny: To address this epidemic, the medical community needed to prescribe opioids more carefully. When we first started to say that addiction is common in pain medicines and what doctors were told about them wasn’t true, they kind of looked at us like who are these mean guys?
The medical establishment was not yet ready to hear what we were saying. Now evidence is overwhelming that overprescribing has caused the epidemic. Leaders in the field have joined our side of this argument. There aren’t many folks arguing that opioids should be prescribed aggressively.
Our messages were explicitly countering the myths that led to overprescribing. A lot of doctors were getting misinformation from the pharmaceutical companies marketing to them, which the Food & Drug Administration allowed.
MAR: What specific actions have you taken with the FDA?
Kolodny: PROP filed an administrative request to the FDA to make the wording on opioid labels less broad so that the companies couldn’t promote them as causing long-term changes in treating patients’ pain. While we didn’t get everything we wanted from the label changes, the effort to change opioid labels was a turning point in awareness in the medical community that opioids have not been demonstrated to be effective for long-term use.
MAR: What is the main obstacle you’ve faced, and how can it be addressed?
Kolodny: The opioid lobby – big pharma, generic manufacturers, pain practices, and wholesalers – has been effective over the past decade at blocking every effort to reduce prescribing, which would reduce profit. They are trying to block the Centers for Disease Control from releasing a new opioid prescribing guideline in January. They make the same argument about how guidelines would punish pain patients. However, the driver is that millions of Americans develop opioid addiction by taking pills as exactly as prescribed by their doctors. When the front groups, intended to look like they advocate for pain patients, that do their dirty work are exposed, that’s good. Senate Finance Committee has investigated these groups.
MAR: How satisfied are you with the impact you’re so far?
Kolodny: It’s difficult to determine how much credit PROP gets versus the overwhelming data that’s becoming available, but we’ve had a major impact. The medical community had been duped into thinking of prescribing opioids as evidence-based treatment for chronic pain. We’ve reached a turning point in awareness internationally. It will take some time, but we’re already beginning to see a plateau in opioid prescribing. It’s definitely not going up. Over time, the medical community will decrease its level of prescribing opioids.