Page 11 - Volume 70 Number 2
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Is the Problem Poor Prescribing or Poor Pain Management?
By Richard E. Burney, MD
Comments from two leading experts, Dr. Dan Berland and Dr. Poojah Lagisetty
If you are a physician who regularly sees patients with substance use disorder (SUD) you might well be happy with the new law, because you have seen the consequences of inadequate pain management as well as inappropriate prescribing practices, both of which are all too common. In fact, you might think the new law doesn’t go far enough, because you can fully appreciate the extent of the problem and the difficulty of correcting it. You might not focus so narrowly on opioid prescribing which has received all of the attention, but also on benzodiazepine (BZD) and amphetamine prescribing. BZD and amphetamines are also addictive and over- prescribed.1 The propensity to develop dependence on benzodiazepines is nearly as strong as it is for opioids and removal from BZD can be more difficult than tapering or removing opioids.
When I was on the Board of Medicine and looking into complaints regarding physicians who appeared to be overprescribing controlled medications, the most com- mon combination of drugs prescribed was oxycodone and alprazolam (Xanax). It was a pill mill specialty. At first I didn’t understand why, but Dr. Dan Berland, a substance abuse expert who served on the Pain and Symptoms Management Task Force for years, explained it to me. The combination of a BZD and an opioid are synergistic for producing a “high” along with the dangers of enhanced sedation and respiratory depression
Dan’s chief concern is that all the attention is on prescribing, when at least as much if not more should be on pain management and the appropriate treatment of frequently-associated mood disorders and on-going social stressers. Prescribers must become trained and comfortable with weaning patients from excessive, unnecessary and harmful controlled medications. Recent articles have also addressed this concern.2
How Do You Wean a Patient Down or Off Controlled Medications?
For patients with substance use disorder, the process is called convert, consolidate and taper. Unfortunately, there has not been much in the literature, , to guide practitioners with specifics of how to do this. It is time consuming and patients can be difficult and demanding. Local specialists Dr. Berland and Dr. Herbert Malinoff described their experience in managing SUD in a 2013 paper in the American Journal of Therapeutics 20, 316–321, entitled “When Opioids Fail In Chronic
Pain Management.”
The patients in this paper are extreme examples of what results from “the sky is the limit” prescribing. Though dependent upon their medications, most of the patients on chronic opioids or BZD, are not seeking euphoria. Still, similar to patients with SUD, they require supportive, but persistent coaching during the process of change. Sadly, there are relatively few prescribers who are trained and competent in this practice.
The Challenge for Primary Care
A recent essay in the one of the major journals de- scribed a primary care physician’s journey from being afraid to take on the task of managing patients with a substance abuse problem to forcing herself to learn how. The Bulletin asked Dr. Poojah Lagisetty, an internist and primary care physician at the University of Michigan and the Ann Arbor VA Hospital, what her thoughts were >>
 Volume 70 • Number 2 Washtenaw County Medical Society BULLETIN 11

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