January 22nd, 2018

The Opioid Epidemic: Further Fallout

Most patients with substance use disorders never enter specialized treatment, such as a residential or outpatient alcohol and drug rehabilitation program. Because of this, I visit the offices of primary care physicians to talk about ways in which they can be of help to their addicted patients.

What I am learning is that most physicians are following the new recommendations from the Center for Disease Control and Prevention to be more cautious about prescribing opioids and tranquilizers. Not initiating these medications is relatively straightforward although not always easy. A more complex issue is what to do about patients who have been taking these medications for years for pain, anxiety, and sleep. These patients are in this situation because of the lax prescribing patterns by physicians that began in the late 1990’s and set off the opioid addiction crisis that continues to plague our country.

Many of these patients have been taking their medication as prescribed, in doses within the therapeutic range. They have not used the medications in problematic ways and therefore do not meet the criteria for a substance use disorder. They are not “addicted” in the current sense of the word – continued use despite adverse consequences. They would, therefore, not be appropriate candidates for a traditional addiction treatment program. They have, however, become physically dependent on the medications because they have been taking them for so many years. They would experience withdrawal symptoms if they stopped taking them abruptly.

What to do about these patients is a question that has been troubling many of the physicians who I have been visiting. This is particularly the case when a doctor inherits patients from a retiring doctor whose prescribing patterns were loose by today’s newer standards. Many of the patients are comfortable taking the medications, are clinically stable, and are not interested in discontinuing the medications. They are often reluctant to switch to alternative medication which do not produce physical dependence but are unfamiliar to them.

There is not yet a standard of care for how to manage these situations without destabilizing patients. The clinical literature on managing this situation is limited, but not entirely silent. I have been fortunate to have as a mentor Dr. Howard Heit, a specialist in working with patients who struggle with this problematic area of physical dependence without addiction. I would invite anyone interested in reading his article about how to approach working with these patients to email me at gkolodner@kolmac.com and I would be glad to send a copy.

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