From crisis to public health emergency: How are practices educating patients about misuse of opioids?

Ninety-one Americans die every day from an opioid-related overdose, as estimated by the Centers for Disease Control and Prevention (CDC), worsening a rising tide of drug overdoses that now are the leading cause of death for Americans under 50.
To put that into perspective: The CDC says opioid-related deaths in 2015 totaled more than 33,000, and almost half of those overdose deaths involved a prescription opioid.

The Trump administration recently declared a nationwide public health emergency in light of the crisis, and the President’s Commission on Combating Drug Addiction and the Opioid Crisis subsequently released its final report, detailing ways in which the 91.8 million Americans who used pain relievers in 2016 resulted in 11.5 million people who reportedly misused pain relievers, including opioids.
A Nov. 14 MGMA Stat poll asked practice leaders if they educate patients on the misuse of opioids. Of 1,029 applicable responses, 61% said they offer patient education on opioid misuse while only 12% of respondents said they do not. Another 27% said their organization does not prescribe narcotics.

Of respondents whose practices do educate patients, most said they rely either on face-to-face education between provider and patient or some combination of that with printed materials or email communications. A number of those polled cited using patient contracts or pain management agreements regarding the specific narcotic chosen for their treatment. (See a sample patient agreement form here.)

Understanding the at-risk population

The commission report noted that multiple studies suggest that people with past use of addictive substances “are at considerably higher risk for prescription opioid misuse,” pointing to a need for better patient screening on drug use histories and heightened “monitoring of and intervention with” at-risk patients, whose misuse of opioids may overlap with other substance abuse issues.

During a roundtable session at the MGMA 2017 Annual Conference on the opioid crisis, multiple attendees — many of them administrators for pain management clinics — noted that one of the largest issues they face is a steady stream of new patients with prior opioid use or substance abuse issues.

“There’s been about 40 practices shut down in the last 15 months for narcotic issues,” said Edward Gulko, MBA, FACMPE, FACHE, LNHA, director, practice management, and interim chief executive officer, SAA, Shrewsbury, N.J., about the situation in his home state. “The biggest problem we’ve seen is what happens to those patients. Most of them are abusers, and other practices don’t want to pick them up … What do you do with those patients when they come in the door?”

For some attendees, a drug screen or substance abuse disorder assessment as soon as the patient looks to become a patient of the practice is a critical part of understanding whether the individual might be at risk for opioid misuse. Even patients who make an appointment sometimes are not advised of the planned drug screen so that the practice can get a good sense of whether the prospective patient has a history of opioid or substance misuse.

Currently, less than two-thirds of U.S. states require a substance abuse disorder assessment prior to prescription.

Combating the crisis

The commission report’s recommendations included a sizable increase in availability of addiction treatment beds, a national drug court system and more than 50 other changes — none of which had any federal spending tied to it, though all 50 states and U.S. territories shared about $485 million in grants overseen by the Substance Abuse and Mental Health Services Administration (SAMHSA) from the passage of the 21st Century Cures Act earlier this year.

Additionally, all 50 states now have prescription drug monitoring programs (PDMPs) to collect data used to better understand and prevent overdoses and deaths, though individual states are seeing varying results in how they approach the opioid crisis.

Officials in Massachusetts recently said opioid overdose deaths are down 10% through the first nine months of 2017, with revival rates on the rise (with increased EMS use of naloxone to combat overdoses) and prescription rates curtailed after a renewed focus on the state’s prescription monitoring program. They also cited an overall climate of focusing on addiction issues rather than any criminal element as contributing to positive outcomes. Local government associations, including ICMA, similarly advocate for local programs that “de-stigmatize opioid addiction and transition … away from a criminal justice approach to a more holistic focus on education and prevention, intervention and support.”

In Kentucky, which has one of the highest rates of drug overdose deaths in the nation in 2015, a Medicaid insurer is testing a pilot program to limit patients to a single provider and pharmacy for their prescription to reduce “pharmacy shopping,” as well as provide access to social workers “to educate them about their disease management and how to take medications properly,” according to Modern Healthcare.

Building a prescription policy for opioids

At least one in 10 American adults experience daily pain, according to the CDC. For prescribing opioids for chronic pain, physician practices should consider the following guidelines assembled by the CDC:

• Don’t make opioid therapy routine: Opioid therapy, if the expected benefits outweigh risks to the patient, should be combined with preferred nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
• Know the care goals: Treatment plans should include when and how opioid therapy is discontinued as patients near their goals.
• Continuing education and evaluation: There is never a bad time to address the risks of opioid misuse with the patient, whether before beginning therapy or while managing therapy. An evaluation of benefits and harms of opioid use should occur between one and four weeks after the start of therapy or after any dosage increase.
• Use proper dosage/duration: Immediate-release opioids at the lowest effective dosage are preferred for starting therapy, prescribed in a quantity no greater than what is required for the duration of pain that is severe enough to require opioids.
• Know the risks: Clinicians should use state PDMP data for patients before starting an opioid therapy and periodically thereafter, whether at every prescription or as infrequently as every three months. Additionally, urine drug testing of patients should precede the start of opioid therapy, with subsequent testing (at least annually) after beginning therapy.
• Be ready to handle misuse: Practice clinicians who encounter patients with opioid use disorder should be ready to offer or arrange treatment, which frequently includes buprenorphine or methadone along with therapy for behaviors tied to substance misuse.

Additional resources

• Prescribing Policies: States Confront Opioid Overdose Epidemic (National Conference of State Legislatures)
• List of evidence-based prevention education programs for substance misuse (SAMHSA)
• Guideline for Prescribing Opioids for Chronic Pain: Recommendations (CDC)
• Guidelines for the Chronic Use of Opioid Analgesics (Federation of State Medical Boards)
• Health Professionals Resources: Safe Opioid Prescribing (Department of Health and Human Services