Improve Prescribing Practices

Introductory Paragraph

Physicians, Dentists, and other healthcare professionals have a key role to play in preventing patients from developing an addiction to pain medication.  Studies have shown that people can become addicted to such medications in a matter of days in some instances.  Reducing over-prescribing while effectively managing a patient's pain is a powerful tool needed to prevent dependence. Prescribing practices must be improved by providing better education in US medical schools about pain management, opioid abuse, and addiction. Other practices that could help reduce the prescription of opioids would be modifying regulations surrounding direct to consumer advertisements by pharmaceutical companies and limiting the ways in which they can influence doctors, such as restricting gifts, vacations, and other forms of compensation.

Key Information

Insurance Company Practices Contribute to Over-Prescription of Opioids

The over-prescription of opioids is largely a result of the US health insurance structure. Unlike countries that provide universal health care funded by state taxes, the United States has a mostly privatized system of care. And experts say insurers are much more likely to pay for a pill than physical therapy or repeat treatments. “Most insurance, especially for poor people (Medicaid), won't pay for anything but a pill,” Judith Feinberg of the West Virginia University School of Medicine. “Say you have a patient that's 45 years old. They have lower back pain, you examine them, they have a muscle spasm. Really the best thing is physical therapy, but no one will pay for that. So, doctors get very ready to pull out the prescription pad. Even if the insurance covers physical therapy, you probably need prior authorization which is a lot of time and paperwork.”

The US health-care system is different from other countries' in other ways, too. There is pressure to address pain, and a pervasive attitude that everything is fixable. As a result, doctors in the United States are much more likely to provide painkillers than are doctors in other countries. One comparative study found that Japanese doctors treated acute pain with opioids about half the time. In the United States, the number was 97 percent of the time.

 

CDC Guidelines for Prescribing Opioids for Chronic Pain

The Center for Disease Control and Prevention issued 12 recommendations for primary care providers, who account for nearly half of opioid prescriptions . The agency highlighted three of them:

• Non-opioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care.
• When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose.
• Providers should always exercise caution when prescribing opioids and monitor all patients closely.

The idea is to encourage doctors to be more cautious about prescribing opioids, making them less likely to distribute the drugs to patients who are prone to addiction or don't really need the medication. (The evidence on whether opioid painkillers can even treat chronic pain is weak at best.) And if doctors take up the recommendations, they could help stop one of the deadliest drug epidemics in US history.

Relevent Research

Opioid Naive Patients Many patients just want relief from pain, and they may not be aware of the risks or alternatives. Doctors who prescribe opioids should take steps to ensure that patients are not "opioid naive". Patients who are considered "Opioid Naive" should receive education and screening for risk factors.
  Multiple studies (five of which are referenced in this UpToDate article) have reported an increased risk of new persistent opioid use after prescription of opioids for acute pain in opioid naïve patients

Other Risk Factors This UpToDate article cites 2 studies and concludes: "Risk factors for persistent opioid use after surgery include preoperative pain; medical comorbidities; depression; a history of drug, alcohol, or tobacco abuse; lower socioeconomic status; and use of benzodiazepines or antidepressants."

Impactful Federal, State, and Local Policies

Long before the current opioid epidemic, most states developed drug-tracking systems to allow physicians and pharmacists to check patients’ prescription drug use, including opioid painkillers, to determine whether they may be receiving too many pills, at too high a dose or in dangerous combination with other medications such as sedatives and muscle relaxants. But few prescribers took advantage of the systems.

 

• Until states began requiring physicians to use prescription drug-monitoring programs, fewer than 35 percent of medical professionals used the tracking systems to identify patients who may be at risk for addiction and overdose. Now, in states that require doctors to consult PDMPs, physician usage rates exceed 90 percent.
• Overall opioid prescribing has declined in those states as well, as have drug-related hospitalizations and overdose deaths. States also are seeing a rise in addiction treatment as more doctors refer patients to treatment after discovering they are taking painkillers from multiple sources and are likely addicted.
• In 2010, Colorado, Delaware, Louisiana, Nevada and Oklahoma were the first states to require doctors and other prescribers to search patients’ drug histories before prescribing opioid painkillers, sedatives or other potentially harmful and addictive drugs. By December 2016, at least 31 states were requiring prescriber use of PDMPs.
• This year (2017), eight more states — Alabama, Alaska, California, Florida, Michigan, South Carolina, Texas and Wisconsin — implemented policies requiring doctors to not only log in to the state’s prescription drug-tracking system before prescribing a controlled substance, but also to analyze each patient’s history of drug use, and if necessary, limit prescription renewals for opioids and other potentially addictive or dangerous medications.

 

Available Tools and Resources

DrProveIt A new technology-enhanced approach to patient understanding and education is available through DrProveIt.com . Patient understanding of risks should be assessed, and information should be provided to address gaps in understanding of the risks.

GuideMed One option to essentially outsource some of the added requirements for opioid prescribing is to work with a third party that integrates with the prescribing process to follow the recommended best practices without adding to the burden of the prescribing physician. You can learn more about GuideMed at their Website This added service allows insurance to be billed for a more complex Evaluation and Management code (99213) instead of the typical code (99212), and this adds about $30 to the revenue for each visit.

MEDITECH is one example with their new (2019) module, the Opioid Stewardship Toolkit.

Promising Practices

Ohio's Safety Checkpoints

Ohio has developed an approach to "safety checkpoints" to minimize inappropriate prescriptions but still allow people who need them to be able to get them--with some added precautions.

 

Sources

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