Patients who take opioids or other controlled substances will be under greater scrutiny beginning Saturday, when doctors in Wisconsin will have to start checking a database of drugs previously given to patients before they write certain prescriptions.
Doctors’ mandatory use of the state’s Prescription Drug Monitoring Program, meant to prevent patients from “doctor shopping” for narcotics and ensure they are using potentially dangerous drugs appropriately, comes after the state Medical Examining Board issued opioid prescribing guidelines last year.
The guidelines have led doctors to require more patients to undergo urine tests to get some medications and prescribe naloxone, the overdose-reversing drug, to patients on high doses of opioids in case problems arise at home.
The moves are part of Wisconsin’s HOPE (Heroin, Opioid Prevention Education) agenda — bills passed by the Legislature in recent years to combat drug overdose deaths. The state had 872 such deaths in 2015, more than two-thirds of which were from opioids, such as oxycodone, hydrocodone, morphine, fentanyl and heroin. The rate of drug overdose deaths increased 48 percent over the past decade, though opioid deaths dipped slightly in 2015.
Amid the new regulations and guidelines, medicine is undergoing a cultural shift. Pain was recognized as a vital sign two decades ago, leading doctors to prescribe more painkillers. Now, in response to overdose deaths and opioid abuse, they’re holding back, sometimes recommending exercise, yoga or over-the-counter pain relief instead.
“We’re trying to convince doctors to prescribe less because patients don’t need that much. Why have it in the medicine cabinet for a year?” said Dr. Gregory Love, a pain management doctor at SSM Health Dean Medical Group.
“We’ve been a little cavalier about the safety of opioids for a long time nationwide,” Love said.
Dr. Alaa Abd-Elsayed, director of UW Health’s pain management clinic, plans to use a grant from the Centers for Disease Control and Prevention to educate primary care doctors about appropriate use of opioids and alternatives such as other medications, steroid injections, nerve blocks and surgeries.
“A lot of providers don’t have the full knowledge of what is going on with opioids,” Abd-Elsayed said. “They keep prescribing them because they don’t know about the alternatives.”
The Prescription Drug Monitoring Program has required pharmacies and other drug dispensers to report controlled substances given to patients since the program started in 2013. But doctors haven’t been required to check the database when prescribing narcotics and other monitored drugs, though many have done so voluntarily.
That changes Saturday, when Wisconsin will join 30 states with mandatory programs. Exceptions to doctors’ required use of the database in Wisconsin include prescriptions lasting three days or less, hospice care and certain emergencies.
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“It’s a tool to help health professionals make informed decisions in light of the opioid abuse problems in the state and around the country,” said Chad Zadrazil, who oversees the program at the state Department of Safety and Professional Services.
Even voluntary use of the system appears to have contributed to a decline in opioids dispensed, Zadrazil said. About 147 million doses were given out during the second half of last year, down from 166 million doses in the second half of 2015, state reports say.
A few states, including Connecticut, Maine, Massachusetts and New York, recently started prohibiting doctors from prescribing opioids for more than seven days for many patients, said Sherry Green, president of the National Alliance for Model State Drug Laws.
Wisconsin’s medical board guidelines, based on guidelines issued last year by the CDC, say doctors should avoid opioids as the first option to treat pain, use the lowest dose of opioids possible, avoid opioids for patients taking benzodiazepines and explain to patients that opioids can be addictive and deadly.
The guidelines also call for periodic urine testing and prescribing of a nasal spray version of naloxone to patients on high doses of opiods and those on lower doses who have depression, a history of overdose or other risk factors.
Some patients balk at urine testing, which doctors at clinics and hospitals in Madison have started doing more routinely, but it’s not done only to check for other drugs they might be using, said Love, of SSM Health.
“You need to be sure the patient has metabolized the medication OK,” he said. “It really is a patient safety issue.”
Test results remain part of the patient’s confidential medical record and are not shared with law enforcement or government agencies, he said.
Abd-Elsayed plans to conduct education sessions with doctors about opioids, but for now he is encouraging them to provide naloxone to the appropriate patients. “It’s not a common practice, but it should be,” he said. “It’s an urgent public health problem.”
Love said the cultural shift away from prolific prescriptions for painkillers seems to be sinking in with patients.
“Rather than having patients say, ‘Why am I only getting 60 pills?’ many patients are now saying, ‘Why are you giving me so many?’ ” he said.
[Editor's note: This story has been updated to reflect a correction. Dr. Gregory Love, a pain management doctor at SSM Health Dean Medical Group, is no longer chief of pain management due to a recent change in department leadership.]