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Readers Write: Can Appropriate Prescribing Practices Curb the Opioid Crisis?
Can Appropriate Prescribing Practices Curb the Opioid Crisis?
By Victor Lee, MD
Victor Lee, MD is VP of clinical informatics at Clinical Architecture of Carmel, IN.
According to a 2014 report from the National Institute on Drug Abuse, the misuse and abuse of opioids is associated with a staggering number of emergency department visits, hospitalizations, overdose deaths, and many other adverse outcomes. Altarum estimates the economic impact from 2001 to 2017 to be more than $1 trillion, with a projected $500 billion of additional cost through 2020 at current rates. The White House Council of Economic Advisers estimates a burden of $504 billion in 2015, stating that prior estimates of the economic costs of the opioid crisis undervalue overdose fatalities. On October 26, 2017, The United States Department of Health and Human Services declared the opioid crisis to be a nationwide public health emergency.
There are efforts to combat the opioid crisis at many levels, including government (federal, state, and local), professional societies, health systems, health plans, academic institutions, and health IT vendors. Let’s look at a few selected recent events. The President’s Commission on Combating Drug Addiction and the Opioid Crisis provides a multifaceted set of 56 recommendations across categories that address federal funding, prevention, and treatment of opioid addiction. The Centers for Medicare & Medicaid Services issued a final rule which implements the Comprehensive Addiction and Recovery Act of 2016 and states, “a sponsor can limit at-risk beneficiaries’ access to coverage for frequently abused drugs beginning with the 2019 plan year. CMS will designate opioids and benzodiazepines as frequently abused drugs.” The Institute for Healthcare Improvement summarizes four main drivers to reduce opioid use, one of which is to limit the supply of opioids.
The Role of Opioid Prescribing as a Contributor
Why is it necessary to limit the supply of opioids? There is clear evidence that the prescription of opioids for pain management is a major driving force of the opioid crisis in the United States. A case-cohort study by Bohnert et al (2011) links higher opioid doses with opioid overdose death among US veterans. A retrospective cohort study by Brat et al (2018) shows that compared with opioid dosage, opioid prescription duration is even more strongly associated with misuse and overdose in a general surgery population. Findings from a series of structured interviews by Cicero et al (2017) reveal no qualitative differences in the onset and progression of opioid substance use disorder between medically treated patients and recreational opioid users. A review article by Compton et al (2016) provides further discussion of opioid prescriptions resulting in non-medical opioid and heroin use and cites numerous references.
Perhaps the most comprehensive review of risk factors for prescription drug misuse is provided in a 2017 publication by the Substance Abuse and Mental Health Services Administration. In summary, the body of research on prescription opioids shows a consistent link with resultant substance use disorder. This suggests that the demand side of the opioid crisis is critically important to address.
A Potential Solution
Prescribers of opioid medications are in an excellent position to fight the opioid crisis. While there are numerous evidence-based guidelines, a reasonable starting point would be to follow the “CDC Guideline for Prescribing Opioids for Chronic Pain” for appropriately selected patients. Recognizing that other opioid prescribing guidelines exist, the CDC guidelines are most commonly referred to by numerous organizations as part of a multifaceted approach to mitigating the opioid crisis.
While guidelines, clinical trials, reviews, and other literature may be widely available, they are not always translated into practice when applicable. This is where clinical decision support (CDS) may help. Kawamoto et al (2005) systematically reviewed the literature and found that the automatic provision of CDS as part of clinician workflow is 112.1 times more likely to improve clinical practice as compared with control groups (P< 0.00001).
CDS can lower the barrier to adhering to certain CDC recommendations such as:
- Calculating morphine milligram equivalents (MME) dosages and justifying decisions to use ≥ 50 MME/day or ≥ 90 MME/day
- Identifying risk factors for opioid overdose and considering of naloxone as part of an opioid management plan
- Applying other prescribing best practices from the CDC’s 12 recommendations
We’re In This Together
While there are other ways to address the opioid crisis — such as national legislative / regulatory action, statewide technology implementation of prescription drug monitoring programs, and treatment of substance use disorder — there is also an opportunity to prevent opioid overutilization in the first place. If a bathtub is overflowing, the question is not whether to turn off the water, unplug the drain, or to mop up the water—the question is how to do all of these things in the most expedient way to address the problem.
Similarly, lawmakers, administrators, technologists, clinicians, and patients can work together to contribute their efforts in concert with one another to optimize pain management, minimize opioid overutilization, and to effectively treat substance use disorders.
We need to get past the opioid crisis coming from legitimate MD prescribed pain management. The opioid crisis is a heroin fentanyl crisis. In EVERY state that has LIMITED opioids or reduced legitimate opioid prescribing the rates of illegal use and overdoses have soared. In the states with the MOST opioids prescribed, the rates are among the lowest. If you restrict legal, MD prescribed use, then people in pain will go to the illegal route. That is a fact. Once they are there, its over. We need to get the NON-physicians, politicians and governments out of the exam room and the cookbook arbitrary MEDs and dosing. The government actually WORSENED the crisis by threatening financial penalties to MDs that did not meet patient satisfaction with pain control. Yes you read that right. The Joint Commission also made similar threats, including their love of the 5th vital sign and recommending the overprescribing of narcotics. So now, they have swung the pendulum fully opposite. Its about time to let MDs be MDs and stop the madness.
I believe that we should let doctors be doctors, that they are the experts in how to care for their patients, and that patients should receive the pain medication they need. And there are many variables (socioeconomic, mental health, etc) contributing to the crisis.
HOWEVER….
Last year, my son had to have 4 planned surgeries, yielding a prescription for Oxycodone 4 times, totaling 120 tablets. He only used about 1-2 each time before comfortably moving to Advil/Tylenol to manage his recovery. If I was unaware of the risks or genuinely believed I should give him everything he was prescribed over the course of many days (as we are instructed to do for antibiotics, etc), I could have given him far more. It’s also easy to see that a parent may make the bad choice to dip into the remaining supply if they happen to get hurt. Addiction can start this way, and the risk could be reduced by more limited prescribing.
By the 4th surgery, I had a lengthy conversation with a nurse in the PACU (at the world-renowned facility in which we had sought my son’s care) about how they determine the prescription amount. She said each Dr makes very different decisions, even with the same exact procedure (such as a hip replacement). She also said that they can be heavily influenced by patient request.
Perhaps in some cases my son might have needed more than 1-2, but perhaps giving him a 2-week supply of Oxy, without even requiring me to call back after a few days to discuss his pain level and seek a refill is simply reckless.
I never filled the 4th prescription (I showed the previous prescription to the nurse and confirmed the medication was the exact same and that he could take 1-2 tablets from that bottle), and have safely disposed of the remainder. But it certainly gave me good reason to think about how our healthcare system is readily prescribing unnecessary opioids.
Let’s not forget that “the experts” supposedly bought into the since rebuked claim that opioids taken for pain do not form an addiction. Most did not question the drug companies peddling that lie. Here’s some information on the rise of Oxycontin prescriptions:
https://www.theguardian.com/us-news/2018/feb/13/meet-the-sacklers-the-family-feuding-over-blame-for-the-opioid-crisis
Lets not forget that CMS and State Medical Boards and Joint Commission ALL PENALIZED MDs for not controlling pain to the CMS’s patient’s self reported satisfaction, threatened loss of licensure and penalties from Joint Commission all in the last decade. We do not have a huge prescribed narcotic epidemic. We have an illegal use of drug epidemic. The focus on prescribed use of narcotics will NOT fix the problem. We could go further and say that online grading of MDs with stars, MANY times is because patients feel they did not get adequate pain control/pills. Beware of the 5 star MD.