A new Health Trends study released by Quest Diagnostics has highlighted many physicians' overconfidence in their ability to identify and treat substance misuse, as well as concerns that the drug gabapentin is increasingly being misused.

The report combines a survey of 500 primary care physicians with an analysis of clinical drug monitoring ordered by physicians through Quest Diagnostics.1

Medication misuse was widespread in Quest Diagnostics' drug tests, with 51% of patients showing signs of misuse and 24% combining their controlled medications with other substances. Despite these widespread practices, however, 72% of physicians said they trusted their patients to take their controlled substances as prescribed.1

Jeff Gudin, MD, senior medical advisor for Quest Diagnostics, said he had almost no exposure to identifying and treating substance abuse during his time in medical school.

"Most doctors, just by nature, have basically ignored if somebody comes in with overt signs of opioid use disorder, have ignored treating those patients, and have not know what to treat," Gudin said.

He added that the lack of education for physicians around medication misuse and substance abuse disorders could lead to the physician's overconfidence that they found in the survey.

Emily Feinstein, JD, chief operating officer of the Center on Addiction, added that physicians are subject to the same stereotypes as others regarding what addiction looks like, so improving education on how to recognize patients struggling with substance addiction is vital.

"The truth is that it's not transparent," Feinstein said. "People with addiction are just regular patients."

The survey also found that the vast majority of physicians want more education on their role in prescription drug misuse, and that they see prescription drug monitoring as part of the solution. Specifically, 70% wished they had more training on how to taper their patients off of opioids, and 76% want more information on how to monitor for prescription drug addiction.1

The discussion around appropriate tapering or discontinuation practices for patients with long-term opioid use comes just after the Department of Health and Human Services (HHS) announced changes to their guidelines. Instead of the formerly strict guidelines which advised tapering patients off of opioids, the new guidelines emphasize the importance of gradual change. Individual patients and public health only benefit from opioids when the benefits of use outweigh the risks.2

Gudin said many medical facilities have implemented mandatory continuing education credits regarding opioid safety.

Taking patients off of opioids too quickly c ould lead to other issues. In the report, 72% of physicians expressed concern that chronic pain patients will turn to illicit drugs if they do not have access to prescription opioids.1

"We see that patients are resorting to things like CBD and marijuana and borrowing pills from friends," Gudin said.

Another important aspect of the report discussed the increasing misuse of gabapentin, an anticonvulsant medication that can be used to relieve neuropathic pain.1 While not an opioid, Gudin said the mind-altering effects of the medication could lead to misuse in patients who are more likely to seek out a clouded, 'high'-like effect.

Its effects can be increased when combined with opioids, but combining the drugs also substantially increases the risk of overdose.1 Several states have recently classified gabapentin as a controlled substance, including Kentucky, Michigan, and Tennessee.3

Gudin himself said he has prescribed gabapentin many times, but has recently begun to realize the dangers of the drug. Gabapentin misuse rose 40% between 2017 and 2018, however, and 34% of physicians reported being concerned about the potential misuse of it.1

Finally, Gudin said pharmacists play a vital role in ensuring the safety of patients dealing with pain. Not only are pharmacists responsible for overseeing all of a patient's medications versus only the 1 or 2 that a physician might prescribe, but pharmacists have increasingly become vital members of the pain care team.

Feinstein added that medication misuse may be intentional, but sometimes it may also be a result of patients' lack of education on proper medication management.

"The pharmacist should never assume that patients know if even what they're taking is an opioid or a benzodiazepine, and they should never assume that patients know not to mix it," Feinstein said.

Pharmacists are often the first to recognize when a patient may be misusing their medications, whether there's a duplication of therapies or they're getting prescriptions from multiple providers. Pharmacists are also vital to educating patients on proper storage and disposal, which Gudin said can be a major key in preventing misuse or substance abuse disorders.

While there's no simple solution, careful screening before prescribing pain medications and while patients are taking them is vital, Feinstein said. She added that investing in the development of new, non-controlled medications to treat pain is important, as is pushing insurance providers to pay for non-pharmaceutical interventions such as rehabilitation and other addiction treatments.

REFERENCES
  1. Health Trends: Drug Misuse in America 2019 [report]. Quest Diagnostics, Secaucus, NJ; Oct. 16 2019: Email. Accessed Oct. 14, 2019.
  2. HHS Announces Guide for Appropriate Tapering or Discontinuation of Long-Term Opioid Use [news release]. Washington, D.C.; October 10, 2019: US Department of Health and Human Services. https://www.hss.gov/about/news/2019/10/10/hhs-announces-guide-appropriate-tapering-or-discontinuation-long-term-opioid-use.html. Accessed October 15, 2019.
  3. Buscaglia M, Brandes H, Cleary J. Special Report: The Abuse Potential of Gabapentin & Pregabalin. Practical Pain Management. https://www.practicalpainmanagement.com/treatments/pharmacological/non-opioids/special-report-abuse-potential-gabapentin-pregabalin. Accessed October 15, 2019.