We all know about America’s opioid problem: prescription narcotic overdoses that kill more Americans every year than firearms or motor vehicles.

In my 4 years of locums, I’ve seen practices who did and who didn’t deal well with prescriptions for scheduled drugs. I worked in one location where 12 weeks of patient care failed to bring me even one drug-seeker. At another place, the opioid standard seemed to be never less than 60 MME per day per patient.

As the epidemic has unfolded, my locums have shown me various ways of approaching the problem. Overall, 6 clinics succeeded and 3 didn’t—here are a few lessons learned.

Success Starts at the Bottom

At five installations, something bad happened that made every doctor realize that they were part of the problem. Meetings generated strategies and documented no-exception policies to pill counts, urine drug screens, and written controlled substance agreements (so-called narcotics contracts), though the details differed. They all limited the number of pills given for acute pain.

What happened? Each spot had a different tale. An overdose death, a call from a licensing entity, or a colleague’s arrest can shake anyone’s complacency.

Every Doctor Has to Be on the Same Page

Some new grads came to a town we’ll call Shangri-La, where the previous docs and patients expected over-prescriptions. The new permanents quickly recognized the problem. A couple of meetings devised a strategy that all accepted. By the time I arrived 4 years later, they had a local reputation for being generous to the terminal, reasonable to those with burns, fractures, kidney stones, or gout, and sticking to their guns.

Go By the Book: Run a Lot of Drug Screens, Make Controlled Substance Agreements

At a staff meeting in a town that I’ll call Despair, a doc said, “I didn’t get a drug screen because she’s 72. She’s somebody’s grandmother.”

The conversational tide changed before I could say, “In the 21st century, assume nothing.” Diversion may be initiated by the patient, or by someone else, with or without consent.

Despair’s approach didn’t work; that staff meeting concerned the practice’s drug problem. Docs can think they can judge character (I know I can’t) until they actually run the urine drug screens and do pill counts.

Erosion, Not Cataclysm

Aside from the practice without a problem, every other successful practice made gradual changes. Some focused on the most difficult patients, some on the heaviest users, one on the heaviest over-prescribers. Chronic users got tapered. Each practice worked hard and faced a lot of anger. But in the long run, those practices had less burnout and higher morale than the heavy prescribers.

One Bad Apple Spoils the Program

I worked for three months with 14 docs in an isolated spot not really called Doorstop. Three years prior, they realized the opioid prescription rate exceeded anything reasonable. One close-to-retirement doctor agreed at meetings but prescribed opioids in defiance of logic. I learned after I left that doctor lost licensure subsequent to a narcotics sting operation.

One Practice Never Had to Change Prescription Habits

In a small town whose real name should have been Success, sometime last century a doctor arrived who never bought into the idea of “pain as the 5th vital sign.” He never drank the opioid kool-aid and he didn’t think much of scheduled drugs outside of end-of-life. He readily convinced the rest of the tiny medical community. They always stuck to the principle of the least medication to get the job done. The town has a high collective life expectancy, and the drug abusers can be counted on one hand.

Disregard Press-Ganey Scores

The successful physicians all decided to ignore the Press-Ganey scores. At a place I’ll call Transparency, the CEO accepted the doctors’ unanimous recommendation. I arrived to clear policies, a subculture friendly to non-opioid pain management, and a low community demand for narcotics. Support staff routinely printed out PDMP reports before being asked.

Good Leadership Can Shield the Medical Staff from Administration’s Meddling

In a town not called Gold Coast, the medical staff had an exceptional leader who never let administration make clinical decisions. In fact, I never heard directly from Admin during my stay. The medical staff had successfully addressed a number of problems before I arrived, including controlled substances.

In contrast, another facility I’ll call Frostbite, Admin disrupted attempts by the docs to establish effective leadership, made sure the physicians met where they couldn’t really talk, frequently canceled the meetings, and polluted the electronic channels daily with literally hundreds of emails.

Overall, the whole opioid scene is changing. Prescription drug monitoring program websites have come a long way in the last 4 years. Because we are good at learning from the mistakes of others, and since the majority of us have been touched by a prescription opioid overdose death or near-miss, as a group we have become less naïve and more cautious. We are improving.

Dr. Steven F. Gordon is a family physician and a 2018–2019 Doximity Author.