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 it is possible for people to become addicted to such medications in a matter of days. Reducing over-prescribing is a powerful tool needed to prevent dependence. Prescribing practices could be improved to reduce the prescription of opioids by:

• providing better education in US medical schools about pain management, opioid abuse, and addiction
• modifying regulations on direct advertisements by pharmaceutical companies
• limiting the ways companies 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. According to Judith Feinberg of the West Virginia University School of Medicine: “Most insurance, especially for poor people (Medicaid), won't pay for anything but a pill. 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 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

In 2019, The Center for Disease Control and Prevention issued 12 recommendations for primary care providers, who account for nearly half of opioid prescriptions. If doctors take up the recommendations, they could help stop one of the deadliest drug epidemics in US history.Three of the recommendations are listed below:

• 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.

Relevant Research

UpToDate

This medical research resource is hosted by Wolters Kluwer, a global provider of professional information, software solutions, and services for clinicians. Two relevant conclusions follow:

• Opioid Naïve 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 naïve". Patients who are considered opioid naïve should receive education and screening for risk factors. Five cited studies reported an increased risk of new persistent opioid use after prescription of opioids for acute pain in opioid naïve patients. "Importantly, post-surgical opioid prescription in opioid naïve patients is also associated with an increase in overdose and misuse."

• Other Risk Factors -- A summary of two citations 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. However, few prescribers took advantage of the systems.

• Until states began requiring physicians to use prescription drug-monitoring programs (PDMPs), 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.
• In 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

SAFE Project:

• See the wiki titled "Expand and Enhance Prescription Drug Monitoring Programs (PDMPs)" for more detailed information on improving Prescription Drug Monitoring Programs (PDMPs) which are among the most promising state-level interventions to improve opioid prescribing, inform clinical practice, and protect patients at risk.

Promising Practices

Ohio's Safety Checkpoints

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

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