Doctors rethink pain treatment

What’s now known about opioids: They are highly addictive and may not be the best choice for pain
Dr. P. Tennent Slack treats a patient for thoracic joint arthritis pain during a procedure where he injects a steroid based numbing medication. Slack is a pain medicine doctor who practices in Gainesville and Braselton. He has been a prominent voice in Georgia about the need for doctors to be more thoughtful and discriminating when prescribing pain medications. BOB ANDRES /BANDRES@AJC.COM

Credit: Bob Andres

Credit: Bob Andres

Dr. P. Tennent Slack treats a patient for thoracic joint arthritis pain during a procedure where he injects a steroid based numbing medication. Slack is a pain medicine doctor who practices in Gainesville and Braselton. He has been a prominent voice in Georgia about the need for doctors to be more thoughtful and discriminating when prescribing pain medications. BOB ANDRES /BANDRES@AJC.COM

Dr. Don Teater didn’t start out declaring war on opioids. In fact, as a small town family doctor, he prescribed them.

“I heard the message from the pharmaceutical industry and the government and others that we weren’t treating pain well enough, that we need to prescribe more opioids — and that it was very safe,” Teater said.

So, like most doctors in America, he embraced opioids as a long-awaited answer for patients suffering with pain.

Before long, inside the exam rooms in his western North Carolina office, Teater saw the dark side of pain pills. Some of his patients, once they started opioids, had a terrible time getting off of them. Others got lost in full-out addiction. Teater decided to try to attack the problem by offering addiction treatment and was overwhelmed with patients seeking his help.

When he took their patient histories, he heard over and over again how it all started: A doctor told them to take an opioid for pain.

And they did.

Today, this small-town doctor who never felt comfortable in the spotlight has become a passionate voice calling on his colleagues to stop doling out these pills. In hotel ballrooms at conventions and at medical society meetings, he tells anyone who will listen that the drugs are dangerous. But he also tells them something that’s not so well known and that some other doctors dispute. He tells them the pills don’t actually work as well as most physicians think.

"The drug companies like to use to the word painkillers," Teater said. "They are not painkillers. They temporarily elevate our mood, and that's the best way they work."

While opioid painkillers were initially billed as both safe and the most effective option for all types of serious pain, more and more evidence is suggesting they may live up to neither of these claims. Even so, many doctors across the nation still use them as a matter of routine. In Georgia alone, patients were prescribed more than 541 million doses of opioid painkillers in a recent 12-month period. That’s 54 legal doses for every adult and child in the state.

“I believe at least 90 percent, maybe 95 percent, of opioids are probably inappropriately prescribed,” Teater said, “where there are better, safer alternatives that are not opioids.”

Pressured to prescribe

Gaylord Lopez, a doctor of pharmacy and director of the Georgia Poison Center, shares a few facts about the opioid epidemic in Georgia and around the nation. An investigation by The Atlanta Journal-Constitution found that opioid-related overdoses in the state of Georgia claimed the lives of 982 people last year. The AJC also found that doctors aren't being held accountable when they behave more like dealers than healers. Video by Ryon Horne, Carrie Teegardin and Curtis Compton

While blatant pill mills and rogue doctors have handed out millions of pills for no medical purpose, well-meaning physicians who were trained to aggressively treat pain are also a big part of the problem.

With such a heavy focus on treating pain, prescribing opioids for years seemed like the responsible route.

Once patients start on opioids, they may want to stay on them. The pressure to keep prescribing can be intense when it plays out in the intimacy of an exam room, or when doctors work for a healthcare system that evaluates them using patient surveys and reviews.

Besides, there seemed to be little downside to providing the painkillers.

Dr. Tom Frieden, the former director of the Centers for Disease Control and Prevention, said many doctors were told for years that patients taking opioids for pain would not become addicted to them. “It’s completely wrong, but it’s how a whole generation of physicians was taught and, obviously, we need to reverse that,” he said.

The truth is, Frieden said, that some patients can get addicted to opioids after just three days of taking the pills.

"Any time a doctor writes a prescription for an opiate, they should be asking the question: Is this the first time this patient had gotten an opiate? And, if so, is it really absolutely necessary? Because this is a momentous decision. A first time prescription for an opiate may condemn a patient to a lifetime of addiction," Frieden said. "There are very few medications that we use that kill people as often as opiates."

Research suggests there’s still a place in medicine for these powerful painkillers, Frieden said. It’s just not the widespread use reflected in the prescribing patterns of both yesterday — and today.

“If you’re in great pain from a car crash or surgery, opiates certainly work, and they reduce the pain,” he said. “We do not want to deny people palliation if they are in severe pain. That’s a very important function for opiates.”

But Frieden, now the CEO of Resolve to Save Lives, a global health initiative, said the question about whether opioids work for chronic pain that afflicts people for months, or even years, comes with a much different answer.

“They will certainly reduce the pain in the short term, there is no doubt about that,” he said. “But it’s completely clear that for chronic pain they are much less safe than other medications, and it increasingly appears to be the case that they are also less effective than other medications in the medium and long term.”

A stunning finding

Dr. Don Teater speaks to medical professionals in Madison, Wisconsin

icon to expand image

When Teater speaks to doctors and dentists at meetings and conventions, he hammers the point that no research supports the use of opioids for months on end. “There was no evidence that they worked for long-term pain, but we were all doing it,” Teater said. “We were told you can’t let your patients suffer.”

Teater’s influence isn’t as a ground-breaking researcher or even a pain medicine specialist. He’s just a family doctor who decided to read every bit of research he could about opioids while he was working on a master’s degree in public health and had access to a giant research library. After speaking at meetings, Teater hands out business cards with a bar graph on the back showing what one review of pain control studies concluded: A combo of ibuprofen and acetaminophen can do a better job than oxycodone, an opioid painkiller.

“It’s not widely known and it needs to be,” he said.

This year, Dr. Erin Krebs unveiled early findings of one of the first rigorous research projects to test the effectiveness of opioids for treating chronic pain.

It’s not yet been published, but at the annual meeting of the nation’s general internal medicine doctors, Krebs shared the key revelation.

"Our main finding is that opioids were not better than non-opioid medications in this study," said Krebs, who practices medicine and conducts research at the Minneapolis VA Health Care System. "We found that most people were able to manage their pain just as well with use of non-opioid medications."

It’s a stunning finding for many patients and doctors. “It’s hard to overstate how jarring this change has been for many practicing physicians,” Krebs said. “It’s been a really rapid reversal in terms of the advice they are getting.”

The news leaves many doctors in a quandary.

At a congressional hearing this fall, U.S. Rep. Michael Burgess, a Texas Republican who is also a physician, posed the question to the expert panel. "What's a doctor to do?" he asked. "You have a patient that has a condition that is painful and you want to alleviate that suffering. How do you approach that? Are you not going to use an opiate?"

In response, Dr. Scott Gottlieb, commissioner of the Food and Drug Administration, testified that practices of the past simply had to change. For example, he said, standing orders for anyone in the hospital to get Percocet, if a nurse believed a patient to be in pain, may have been well-intentioned but were wrong. “That wasn’t good medical practice, we now know,” he said.

After just five or six days of exposure to painkillers, Gottlieb said, “some of those patients left the hospital addicted.”

The medical community, he testified, must rethink how these medications are used. “We’re in the process of doing that,” he said. “That’s also going to require us to re-educate a generation of physicians, and that’s what we’re doing.”

Remembering the patient

Dr. P. Tennent Slack treats a patient for thoracic joint arthritis pain during a procedure where he injects a steroid based numbing medication. BOB ANDRES /BANDRES@AJC.COM

Credit: Bob Andres

icon to expand image

Credit: Bob Andres

Dr. P. Tennent Slack, a pain medicine doctor who practices in Gainesville and Braselton, said there’s no question that too many doctors have been “indiscriminate” in their prescribing of opioids.

Prescribing an opioid should never be a quick, easy solution, Slack said. It requires a close evaluation of the patient’s pain and an honest assessment of the patient’s risk of addiction. In every case, Slack said, doctors should consider the alternatives, from the least-invasive — such as bio-feedback — to the most invasive treatment — surgery. When opioids are used, he said, doctors should prescribe the lowest effective dose for the shortest amount of time.

Slack worries, though, about the unintended consequences that could come from the urgent push to address the opioid crisis. When he speaks around the state, he advocates for a solution that balances the need for more careful prescribing with an acknowledgement that some patients do well on the medications and would suffer without them.

"The vast majority of Americans take the opioid pill and they stop," he said. "There are those who make it sound like everybody who is exposed to a narcotic will undergo some sort of change in the brain that will cause them to misuse the medication."

About 97.5 million people across the nation used a prescription pain reliever in 2015, according to the 2015 National Survey on Drug Use and Health. Of those, 87 percent used them as directed, and 13 percent misused the medication. About two million people have a substance use disorder involving pain pills.

Slack speaks to doctors across the state about prescribing as part of a Medical Association of Georgia campaign.

Slack, whose guidelines for being a “discriminating prescriber” are detailed and demanding, said he does have some patients with debilitating pain who do well on opioids. These patients can work, take care of their kids or walk comfortably with the help of pain medications, as long as they are prescribed with care and careful monitoring, he said.

His goal is to make sure these patients aren’t forgotten in the discussion. “The pendulum is headed so far back in the other direction, we’re going to see overly restricted access to opioid therapy to the point there will be some unnecessary suffering out there,” Slack said.

Mick Shannon was a handsome, athletic boy growing up in a Hall County family. He was n track to do anything he wanted in life until he was prescribed pain pills after surgery. (Video by Ryon Horne and Carrie Teegardin)

Getting the message out

The front of Teater’s business card features an image from the Wizard of Oz. The emerald city is in the distance. A giant field of bright-red poppies is in front of Dorothy and her traveling companions — a field created by the wicked witch. In the movie, the group at first is energized and races happily through the flowers. But soon, Dorothy, Toto and the Lion pass out, as the witch intended.

Teater uses the image to remind the doctors he speaks to where poppy-derived opioids come from and how they work. The drugs change how the brain perceives pain. The drugs can produce a sense of calm, pleasure or even euphoria. They also depress respiration.

"In some people, that first dose doesn't necessarily make them feel high, but it makes them feel good," Teater said.

That can be especially true, Teater noticed during his practice, for people’s whose lives are already challenging because of poverty, abuse or their struggle with pain. Patients that Teater treated for addiction often shared that the drugs at first just made them feel more confident, more motivated, more positive about life.

"They come back for their next check up and they're feeling great," Teaters aid. "But that effect doesn't last."

Try to get off the drugs, the pain will seem worse than ever. But getting the same effects over time, Teater said, requires ever higher doses. For those who become addicted, breaking from the drugs can be a long and difficult process. Teater sees that struggle every week in his medical practice, which is now exclusively focused on helping people beat addiction.

Seeing that struggle is why Teater travels across the country, sharing his charts and trendlines and stories about his own mistakes with opioids.

If doctors really knew all they could about opioids, he said, most would almost certainly change their approach to treating pain — if they haven’t already. That’s why this doctor who never liked public speaking does it almost every week. He knows the pharmaceutical industry is a powerful voice, so it will take time and persistence for doctors to change. But he also knows that every time someone who can sign a prescription pad hears his message and makes a change, it’s possible that a patient may be saved from addiction.

"The great majority of people with pain should not be started with opioids," Teater said. "That message is not getting out yet."