Wisconsin Primary Care Doctor Describes Challenges Of Prescribing Opioids

A new report from the Centers for Disease Control and Prevention says opioid prescriptions are down, but still way too high. While doctors are prescribing lower doses, they are still doing so for longer than CDC guidelines say are safe. NPR's Robert Siegel talks to Dr. Alan Schwartzstein, who has worked as a family doctor for 28 years in rural Wisconsin, about the issues surrounding prescribing pain medication.

ROBERT SIEGEL, HOST:

Well, as we've heard, the last year of data included in the CDC's report was 2015. Since then, the agency has released guidelines for prescribing opioids. They're meant for primary care physicians like Dr. Alan Schwartzstein. He's been a family physician for over 30 years. He works in rural Walworth County, Wis. And he's a member of the board of the American Academy of Family Physicians. Welcome to the program, Dr. Schwartzstein.

ALAN SCHWARTZSTEIN: Thank you, Robert.

SIEGEL: Are you prescribing fewer opioids than you used to?

SCHWARTZSTEIN: Yes, I am, absolutely.

SIEGEL: And how many opioid prescriptions do you write now as opposed to five, 10 years ago?

SCHWARTZSTEIN: Well, approximately 15 years ago there was a lot of encouragement from patient advocacy groups, people that had chronic pain, as well as some government organizations for us to prescribe more and do a better job of treating chronic pain. It's just in the last four to six years that we've recognized a significant increase in opioid prescribing. And so during that time I prescribe less. I do shorter prescriptions. And in the last year, I've actually - am actively working with all my patients who are on this to wean them back off, that or use other modalities.

SIEGEL: Are you at all concerned that the pendulum with regard to painkillers might be swinging too far? That is, that doctors might be overly reluctant right now to prescribe opioids to patients who are dealing with chronic pain?

SCHWARTZSTEIN: It's possible. Family physicians have to run a thin line between providing adequate treatment for chronic pain and limiting opioids. I don't think it's going to go too far, Robert. I'm optimistic.

SIEGEL: I have heard from doctors who practice in rural areas that the question of how many pills you prescribe is a tricky one because if you give too few pills, your patient isn't like someone in the city who can check back with you in a few days and have another visit with the doctor. The patient may be 60 miles away from your office. Is that a problem for you in Walworth County, Wis., and how do you deal with it?

SCHWARTZSTEIN: For people that I'm treating with opioids for chronic pain, generally the prescriptions I'm giving them and that I'm refilling for them are for a 28-day period. However, for acute pain, I'm beginning to prescribe shorter durations, actually only three days for someone that comes in with a bone injury or some other reason for pain. And they only needed those three days. And after that they relied on acetaminophen and Ibuprofen and the like.

SIEGEL: In addition to seeing patients at your practice, you also hear from patients who are seeking emergency care. Do you hear different kinds of problems related to opioids there?

SCHWARTZSTEIN: Well, I do. Patients don't generally come in there seeking to get off an opioid. They usually come in on weekends asking for a refill on their medication either because their own physician is out of the office or it's the weekend and they ran out. Generally we get to understand when we should be prescribing for a few days to get them through and when this probably is not an appropriate prescription. And I've had at least three people over the last six months in the urgent care when I declined to write a prescription say, you know, doc, I can go on the street and get heroin or this medicine for cheaper anyway.

SIEGEL: What do you say to someone who says that?

SCHWARTZSTEIN: I hear what you're saying, but ethically I don't feel this is the right medication for you. What you do when you leave is up to you. But I also say to them, you know, if this has become an issue with you of overusing the medication or you feel it might be a problem, I'd like to get you connected with somebody that can help you deal with this and control your addiction.

SIEGEL: What is the opioid situation in Walworth County, Wis.? Do you think the county ranks as one of those with a very large problem or in the middle or a small problem?

SCHWARTZSTEIN: I would say we're probably in the middle. It is a rural county, and we have a large population that is unemployed or underserved. And so opioid addiction and use of opiate medication tends to increase in those areas. And I see that in the area.

SIEGEL: Dr. Schwartzstein, thank you very much for talking with us today.

SCHWARTZSTEIN: Thank you, Robert.

SIEGEL: Alan Schwartzstein is a family physician in southeast Wisconsin.

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