Prescribing Alternatives to Pain Medicines Is Easier Said Than Done, Doctors Say

Andrew Kitchenman | October 2, 2014 | Health Care
Constraints on patients’ time and money, insurance delays cited among obstacles to reducing use of oft-abused opioids

Dr. Noel Ilogu, an addiction medicine specialist at Robert Wood Johnson University Hospital.
There may be ways to treat pain that are safer and more effective than taking prescription opioids. But some doctors say constraints on patients’ time and money, as well as difficulties in getting insurers to agree to pay for such alternatives, can make it impractical to pursue those options.

The importance of finding solutions to this dilemma has become more urgent, as New Jersey and the nation face a rising tide of deaths from the use of prescription narcotics, as well as from heroin.

Dr. Andrea Harangozo, an East Brunswick-based pulmonologist, said some patients can’t afford the copayments for repeated visits to physical therapists or other providers. She added that the traditional first step of having insurers approve payments for treatments — known as precertification — is being delayed by an additional step called predetermination.

“The doctors do not have the time to do this anymore – that’s the reality,” said Harangozo, who is president of the medical staff at Robert Wood Johnson University Hospital in New Brunswick.

She raised these concerns yesterday with a panel of medical experts at a symposium held at the hospital yesterday. The event was the fifth in a statewide series designed to provide doctors with information about prescription drug abuse.

Several speakers cited the importance of the New Jersey Prescription Monitoring Program (PMP) as a tool for helping doctors avoid prescribing drugs to people who are addicted or selling the drugs on the street.

Healthcare lawyer Andrew Blustein said doctors should use the PMP to minimize their legal liability, as part of a broader effort to apply appropriate standards of care for every patient. He warned that every doctor who eventually gets into legal trouble for prescribing opioids thinks “That’s not going to happen to me.”

State Division of Consumer Affairs Director Steve C. Lee noted that only 23.1 percent of eligible prescribers and pharmacists are using the PMP.

“It’s physicians and medical professionals, not law-enforcement agents, who can have one of the biggest impacts on ending this prescription-drug crisis in New Jersey,” Lee said. “As powerful as it is, the NJPMP will not fulfill its potential to fight drug diversion until a significant majority of doctors register and consult it regularly when prescribing opiate painkillers and other controlled medications.”

The state is now making registration in the program mandatory when doctors renew their licenses. In addition, Sen. Loretta Weinberg (D-Bergen) and other lawmakers have proposed legislation to make participation mandatory across-the-board.

But Harangozo said the PMP is cumbersome for time-constrained doctors to use, since it’s not integrated into the electronic systems they use to prescribe all other types of prescriptions. The point drew applause from other doctors in the audience.

Dr. Noel Ilogu, an addiction medicine specialist at Robert Wood Johnson University Hospital, said doctors can use the PMP to identify other doctors who are prescribing irresponsibly.

Ilogu said doctors must recognize that medicine is only one piece of the treatment needed for patients with addictions.

“I only deal with one part — the biological,” Ilogu said. “You need to see a counselor, you need to be involved in 12-step programs, you need to make amends to your family to address the psycho-social” problems involved with addiction.

Ilogu encouraged doctors to advocate for continued funding for programs that treat people with addictions.

Dr. Iqbal Jafri, director of cardiopulmonary services and the pain program at JFK Johnson Rehabilitation Institute in Edison, said all doctors — not just pain specialists — must work to increase their knowledge of pain treatment. As a clinical professor at Rutgers Robert Wood Johnson Medical School, Jafri teaches all third-year medical students about pain medicine.

“Every physician has to see the pain patient,” Jafri said. “Therefore, you cannot just tell the patient, ‘I’m not a pain physician, I’m not going to see you.’ ”

Jafri said it’s important to not treat long-lasting, chronic pain in the same way as short bursts of acute pain.

“You cannot just treat patients with one pill — an opioid — or any other pharmacological agent,” Jafri said.

Jafri urged doctors to consider treatments like acupuncture, massage and non-opioid medications for patients with some chronic-pain conditions like fibromyalgia.

Nationwide last year, more than a quarter of patients on prescription opioids met the psychiatric definition for drug dependence, noted Dr. Shuvendo Sen, associate program director of internal medicine residency at Raritan Bay Medical Center.

Sen said doctors should think twice before prescribing opioids to patients at risk of becoming addicts. Risk factors include being dependent on another substance, including tobacco; having a family member with a substance use disorder; having mental health disorders, including depression or post-traumatic stress disorder; and a history of legal problems or incarceration. He added that teenagers diagnosed with attention deficit hyperactivity disorder are also at risk of addiction.

“If those red flags are present, we’ve got to optimize the alternative treatments,” Sen said.

Sen noted that some doctors — as well as dentists — are under too much pressure to see too many patients too quickly, which also can lead to too many pain prescriptions.

The symposiums are organized by the Partnership for a Drug-Free New Jersey, a state anti-drug agency.