Even as the number of prescriptions for opioid pain medication declines from its peak of about 250 million in 2013, the epidemic of opioid use continues to devastate lives. Some 2 million individuals are afflicted with substance use disorders involving opioids, with approximately 500,000 of them addicted to heroin. Physicians and physician organizations are increasingly concerned that patients with pain who are unable to obtain comprehensive pain relief may turn to cheaper and more available street drugs as an alternative.

Orthopaedic surgeons, who account for 7.7 percent of the total opioid prescriptions dispensed in the United States, often find themselves whipsawed by competing mandates: to curtail the dispensing of drugs to which some people become addicted and to provide optimal and appropriate care to their patients.

The response to the opioid epidemic includes a flurry of measures by legislators and regulators that affect physicians. Perhaps the greatest impact on the daily practice of an orthopaedic surgeon comes from actions taken at the state level, by legislators eager to act decisively against a scourge they see tearing up communities. At the 2016 AAOS Fall Meeting, a symposium was dedicated to issues surrounding the opioids issue and the corresponding regulatory and legislative activity.

The American Medical Association (AMA) provided an overview of state laws and policies at the symposium, which were further explained in an interview with AMA President Andrew W. Gurman, MD, an orthopaedic surgeon from Pennsylvania.

Creative state legislatures
Reviewing the activity in statehouses to address the opioid crisis, Dr. Gurman highlighted that the AMA tracked 600 pieces of state legislation in 2015.

"For 2016, state legislators were even more active," he said. "In 2017, the AMA expects more than 1,000 individual pieces of opioid-related legislation."

Although physicians may view many of the new laws and regulations as burdensome and even counterproductive, they recognize a dire reality, Dr. Gurman said.

"Nonmedical use of opioids hurts people and has ripple effects throughout the system—in emergency department visits, in treatment, and in lack of treatment."

Recently, the Drug Enforcement Agency (DEA) estimated that it had seized about 6 tons of the about 30 tons of pure heroin available at large. That doesn't include the estimated 75 percent of prescription opioids that are diverted, or the fentanyl and fentanyl analogs being shipped in from China and Mexico and other countries.

"These powerful drugs are killing people," said Dr. Gurman. "And in some state legislatures, there is the perception that heroin and other opioid addiction began by a physician 'overprescribing' opioid analgesics to their patients.  The science is much more complicated than that, but it's a political reality that the AMA works to counter on a regular basis."

Making some progress
Another reality is that progress is being made, as measured by the number of opioid prescriptions written by physicians. Dr. Gurman noted that the opioid prescription peak was reached in 2013. Since then, the figure has been decreasing significantly—11 percent from 2013–2015. He anticipates it will continue to drop significantly due to multiple factors, including increased physician judiciousness and new mandates restricting opioid prescribing.

Although the decline in raw prescriptions is a positive, it is not a sharp lens for the current picture.

"I want to point out that we do not know whether the patients no longer receiving an opioid prescription are so-called doctor shoppers or simply suffer from uncoordinated care. In fact, no one knows, which is concerning because we continue to hear from chronic pain patients about being denied their medication," said Dr. Gurman.

For example, he pointed to a recent course he took about prescribing in the field of hand surgery. Following the course, he began prescribing lower amounts of opioids because the data from his colleagues supported that change.

"But it's not one-size-fits-all," he said. "Some of my more complex surgeries require more pain control than others. Each situation must be tailored to the individual patient."

He noted that the AMA—along with the National Governors Association and with the support of more than 25 medical organizations in the AMA Task Force to Reduce Opioid Abuse, including the Academy—has supported the following five general recommendations for reducing opioid abuse and addiction:

• increase registration and use of Prescription Drug Monitoring Programs (PDMPs)
• ensure safe, evidence-based prescribing
• support comprehensive pain care; reduce the stigma of pain
• reduce the stigma of substance use disorder; increase access to treatment
• increase access to naloxone to save lives from overdose; support broad Good Samaritan protections

"These recommendations were developed for physicians by physicians. These are things that we can advocate for in state legislatures and other arenas," he said.

The use of PDMPs
The PDMP is a practical tool that can help physicians make more informed prescribing decisions. About 30 states have functional PDMPs.

"I expect that number to grow," said Dr. Gurman, noting that Pennsylvania has a brand new system so it may take time to know how well it works.

"The AMA expects that many more states in 2017 will seek to require physicians to check the registries before writing a prescription on an opioid—and we will carefully analyze all of those bills," asserted Dr. Guzman.

Flaws identified by physician societies and technical glitches in PDMPs are being addressed, and in general terms, "PDMPs are getting better," he said. The AMA is tracking several court cases involving them, including ones in California and Oregon concerning law enforcement authority to check on an individual physician's prescribing habits without a warrant.

"The AMA position is that law enforcement needs to have probable cause to access a patient's protected health information," explained Dr. Gurman. That position prevailed in Oregon at the district court level in DEA v. Oregon PDMP, and the case has moved into the Ninth Circuit for appeal. A separate case, Lewis v. Medical Board of California is pending decision by the California Supreme Court.

"Law enforcement has an important role to play," he said, "but we want to have standards. The question to ask your state medical society is, 'What is the standard for law enforcement in my state to access the PDMP?' Very few states have a probable cause standard. That's something we can fix in state legislation."

The use of PDMPs is increasing, according to Dr. Gurman.

"Our argument has always been that if you give physicians a good tool, we will use it," he said.

"Doctors are going to use the tools that help their patients, he continued. "In orthopaedic surgery, like almost every other specialty, prescription numbers are going down. In every specialty except for pain medicine—which I think is reasonably attributed to an increase in referrals—the questions are, 'Has patients' pain gone down? Are we treating fewer patients?' Like all physicians, orthopaedists have recognized the need to be more judicious in prescribing. And we also know that some of our colleagues may have stopped prescribing all together."

"Our main concern—like physicians everywhere—is whether our patients are receiving the best care," he added.

What is problematic for the AMA, said Dr. Gurman, is that laws have been enacted that hope to curb opioid misuse, but may instead create harmful unintended consequences. For example, Maine is requiring that all patients be under 100 morphine-equivalent doses by July 2017.

"It's probably going to affect at least 16,000 patients. What is going to happen to them? Where are they going to get additional pain relief?" asked Dr. Gurman.

"In Rhode Island," he continued, "the initial prescription can be no greater than 30 morphine equivalents or 20 doses. This is supposed to be for acute pain. You're going to get more phone calls. Hopefully, they will be good conversations, and we also hope that if state legislative or regulatory fixes are needed, those fixes will be made."

Additional speakers at the symposium included Daniel M. Frohwein, MD, an anesthesiologist, and Adrianna Simonelli, a professional staff member for the House Energy and Commerce Committee. In addition, surveying the opioids issue from a surgeon's perspective was David S. Jevsevar, MD, MBA, chair of the AAOS Council on Research and Quality. An article covering Dr. Jevsevar's remarks will appear in an upcoming issue of AAOS Now.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org