Opioids claimed over 64,000 lives in 2017 and data show an almost fourfold increase in overdose deaths from 1999 to 2008. Yet, opioid medications are still necessary to manage the pain following surgery or injury. So how do we balance the need for pain management with the need to reduce addiction and overdosing?
A real solution will require a systems approach. All players in the healthcare ecosystem - providers, health systems, insurance plans, public health agencies, patients, families, and community organizations - have a role to play. And, the fix must be multi-faceted. Prescribing fewer pills or looking up a patient’s prescriptions in a database are good tactics, but they aren’t enough. Patient education, community outreach, and new guidelines for pain management must be part of the equation, too. That will require a rethink of each step in the patient’s clinical journey.
Here are six things the healthcare industry is doing to ensure appropriate opioid management for pain.
1. A CMS Roadmap for navigating the epidemic
In June 2018, CMS took an important, national leadership stance by publishing the Opioid Epidemic Roadmap. It suggests three key components to addressing the issue: Prevention, Treatment, and Data.
Prevention includes identifying risks and addressing them early - as well as finding alternative ways to control pain. Treatment is self-explanatory and includes the importance of supporting new practices for treating pain. And Data includes not only monitoring of prescription patterns but also sharing data across organizations and the community, watching for trends, and proposing interventions and solutions.
The CMS Roadmap provides a framework that organizations can hang their own initiatives on, while remaining consistent with the CMS recommendations being followed by others.
2. Organizations are reviewing and updating prescribing guidelines
Many organizations are evaluating and improving guidelines for managing acute and chronic pain, making changes to best practices, and using technology systems to alert clinicians about risk issues and prescribing behavior.
For instance, Kaiser Permanente Southern California began working to reduce the inappropriate use of opioids in 2010. The organization implemented restrictions and monitoring technology, and provided clinicians guidance with prescribing and formulary policies. The organization has reduced its prescribing of the highest risk long-acting opioid medications for non-cancer, non-hospice patients by over 72% and high-volume prescriptions of short-acting opioids by 98%.
And last year, Cigna announced that in partnership with more than 1.1 million prescribing clinicians it achieved a 25% reduction in opioid use among its customers. The payor worked with more than 2,000 medical groups to reduce opioid prescribing and to treat opioid use disorder as a chronic condition. Among other initiatives, Cigna used integrated pharmacy, medical, and behavioral health data to suggest to physicians the possible patient misuse or overuse risk of opioids, provided education, and offered a hotline for veterans and their families,
3. New training courses focus on the latest best practices and opioid alternatives
Although only 40% of opioid overdoses involve a prescription medication, 11.5 million people admit to misusing prescription medications, which puts them at risk for addition. And, three out of four heroin users misused prescription medications first.
These data point to a need for training clinicians on methods and tactics that prevent medication therapy from becoming an additional risk. Many organizations are developing programs or leveraging existing continuing medical education (CME) programs such as the American College of Physicians’, the Centers for Disease Control’s training program for prescribing opioids, or SCOPE of Pain, developed by Boston University. All of these efforts are designed to help physicians, nurses, and other practitioners safely and effectively manage patient pain effectively, when appropriate, with opioid analgesics.
4. Prescription drug monitoring programs (PDMPs)
PDMPs are state-based electronic databases that track the prescribing and dispensing of controlled substances. They collect data from pharmacies about which controlled substances were dispensed, how much, to whom, and by whom. 49 states and the District of Columbia have a PDMP, making it easier than it was even a few years ago to identify patients who have sought or been prescribed opioid and other pain medicines prior to their current visit.
These systems have effectively contributed to the reduction in opioid prescriptions by 8% and prescription opioid overdose death rates by 12%. Some organizations have implemented alert features that force clinicians to check the PDMP before an opioid can be prescribed in the EHR.
5. New technologies are improving the accuracy of medication history-taking
Whether in the clinic, emergency department, or hospital admission department, gaining a comprehensive and accurate list of a patient’s medications has always been essential. Today, however, we need increased attention on obtaining detailed information about past and present pain medications. But that’s not easy to get from patients at risk, or those already addicted to controlled substances.
New technology platforms such as Meds360 provide essential information about all prescriptions; not just the ones patients remember or decide to tell their provider about. Meds360 delivers a month-by-month view of real-time, up-to-date medication lists, pick up and refill data, dosage changes, and duplicate prescription. This data comes not just from the EMR but from everywhere - and includes data that covers over 265 million patients, all major pharmacy networks, and a growing number of independent pharmacies, all including cash-pays. Moreover, clinicians accessing Meds 360 controlled substance data in States with PDMP lookup mandates will receive the same credit from the States as if they had done the lookup directly through the PDMP.
6. Coalitions are forming
The interconnectedness among initial pain management, patient education, addiction, and emergency responses to overdose is more than a healthcare problem. It’s a community and public health problem too. SafeMedLA is a good example of how county health departments, providers, payors, and community groups are working together to address prescription drug abuse in the community. And the National Coalition Against Prescription Drug Abuse is an example of a national coalition that provides community education, policy change and legislative advocacy at the national, state, and local level.
 CMS Opioid Epidemic Roadmap, https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Opioid-epidemic-roadmap.pdf