Dr. Ramsin Benyamin views the opioid epidemic almost like he would a patient. If you ask Benyamin how he’d fix the opioid issue—how he’d treat it—he starts with a diagnosis.
Before you can fix the problem, he said, you must understand how we got here.
“There is no one magic wand that you’re going to wave and the problem is going to disappear,” said Benyamin, president of the Millennium Pain Center, which has a location in Bloomington, and an assistant professor at the University of Illinois at Urbana-Champaign College of Medicine. “This is a problem that’s grown gradually, and there’s multiple aspects to it.”
The opioid epidemic has already changed the way Bloomington-Normal doctors treat their patients—from emergency room physicians to pain specialists like Benyamin. Doctors on the front lines are thinking twice about the quantities of opiate painkillers they prescribe, and they’re abiding by a new state law requiring them to a check a patient’s prescription history before giving them narcotics.“There is no one magic wand that you’re going to wave and the problem is going to disappear.”
The overprescription of opiate painkillers is widely considered one of the drivers of the current opioid epidemic. Many addicted patients get their first exposure from a legal prescription, then moved on to higher dose formulations or more accessible illegal street drugs, the FDA says.
This can have deadly consequences, especially as lab-manufactured drugs are added to traditional heroin. Opioid-related deaths more than doubled in 2017 in McLean County to 34 from 15, said McLean County Coroner Kathleen Davis. Seven others died of overdoses involving other drugs.
Doctors have been talking about opioid abuse for at least a decade, said Benyamin, a nationally known pain expert whose Millennium Pain Center has seven locations around Illinois. The media and policymakers are latecomers to the discussion, he said.
The problem traces back as far as 2000, Benyamin said. That’s when the Joint Commission, which accredits and certifies medical facilities, issued new standards for treating patients with pain, he said. That increased focus on pain—when pain became a “fifth vital sign”—is what triggered a sharp increase in prescribed opiate painkillers, he said. Pharmaceutical companies seized the moment, he said.
“There’s a reason why we got here,” Benyamin said.
That focus on pain led doctors to opiate medications, said Dr. Kelley Smith, an attending physician in the emergency department at OSF St. Joseph Medical Center in Bloomington. Like many young doctors, Smith was trained that pain is the fifth vital sign. That’s led to a practice where it’s “easier to give out the pain medication and kind of move people along, instead of sitting down to address the underlying issue.”
If someone truly needs a painkiller, Smith will prescribe it, she said. But the headline-making opioid epidemic now gives front-line doctors like Smith pause about how much they’ll prescribe.
“I will definitely give it a second thought of how much I’m going to prescribe, and what is a reasonable amount for a person to take,” Smith said. “A big part of it is figuring out other ways that people who are using narcotics for pain medications, figuring out how to get them into pain management clinics or other ways to deal with their pain rather than turning to a pill.
“Really we want to treat the underlying problem, and we don’t want people to have to chronically be on medication to do it,” Smith added.
Some of this isn’t optional. As of Jan. 1, a new state law requires drug prescribers to use a database containing patient prescription histories. Physicians who don’t may be subject to state disciplinary action.
Smith did her residency at Southern Ohio Medical Center in Portsmouth, Ohio, where the opioid epidemic is at its worst. She rarely worked a shift there without seeing one or two overdoses.
“Part of the reason it got so bad in Ohio was that there wasn’t a lot of oversight with how many prescriptions could be written, for how much, for how long. So I think that’s one thing that’s already been addressed here (in Illinois),” Smith said.
A related problem is the shortage of effective pain medications that are not opioids, Benyamin said. Insurance companies sometimes do not cover non-opioid alternatives, he said. He recently tried to get Medicaid to cover a non-opioid inflammatory patch for a pain patient, a safer treatment with fewer known side effects. A 30-minute phone call later, Benyamin was told Medicaid doesn’t cover that, only a fentanyl (opioid) patch.
“Imagine that,” he said. “If you’re looking for a solution, you have to address all these issues.”
The worsening opioid epidemic has led to new discussions about pain management protocols across the medical community, Benyamin said. More recent CDC guidelines on dosing have been welcomed by the medical community, he said. Benyamin is past president of the American Society of Interventional Pain Physicians, which contributed to the CDC guidelines.
He said the problem is not just overprescribing—it’s co-prescribing, an issue identified in the CDC guidelines. Benyamin said doctors need to be careful about prescribing opiate painkillers alongside other medications that are considered central-nervous system depressants, like Xanax or valium.
“They make the impact even more serious,” Benyamin said.
There are also not enough resources available to treat addiction, Benyamin said. Insurance companies sometimes don’t cover treatment, he said. Benyamin is also baffled how easy it is for Chinese synthetic fentanyl to be imported into the U.S., worsening the opioid crisis.
“It’s unbelievable how this happens,” he said.