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
CDC Guidelines for Prescribing Opioids for Chronic Pain
- 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.[4]
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[5]That article also states: "Importantly, post-surgical opioid prescription in opioid naïve patients is also associated with an increase in overdose and misuse."
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."[6].
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.[7]
- 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.[8]
Available Tools and Resources
DrProveIt
An 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
MEDITECH is one example with their new (2019) module, the Opioid Stewardship Toolkit
Promising Practices
Ohio's Safety Checkpoints
[9]
Sources
- ↑ [1]Am, closeAm, a E., & EricksonEmailEmailBioBio, a. (n.d.). Analysis | Opioid abuse in the U.S. is so bad it’s lowering life expectancy. Why hasn’t the epidemic hit other countries? Retrieved November 24, 2019, from Washington Post website: https://www.washingtonpost.com/news/worldviews/wp/2017/12/28/opioid-abuse-in-america-is-so-bad-its-lowering-our-life-expectancy-why-hasnt-the-epidemic-hit-other-countries/
- ↑ [2]Am, closeAm, a E., & EricksonEmailEmailBioBio, a. (n.d.). Analysis | Opioid abuse in the U.S. is so bad it’s lowering life expectancy. Why hasn’t the epidemic hit other countries? Retrieved November 24, 2019, from Washington Post website: https://www.washingtonpost.com/news/worldviews/wp/2017/12/28/opioid-abuse-in-america-is-so-bad-its-lowering-our-life-expectancy-why-hasnt-the-epidemic-hit-other-countries/
- ↑ https://www.cdc.gov/drugoverdose/prescribing/guideline.html https://www.cdc.gov/drugoverdose/prescribing/guideline.html
- ↑ [5]The CDC is trying to get doctors to help stop the opioid epidemic—Vox. (n.d.). Retrieved November 24, 2019, from https://www.vox.com/2016/3/15/11236600/cdc-guidelines-opioid-epidemic
- ↑ [3]Carlos A Pino, Melissa Covington,MD, Prescription of opioids for acute pain in opioid-naive patients, UpToDate, May 14,2019, Retrieved from https://www.uptodate.com/contents/prescription-of-opioids-for-acute-pain-in-opioid-naive-patients
- ↑ [4]Carlos A Pino, Melissa Covington,MD, Prescription of opioids for acute pain in opioid-naive patients, UpToDate, May 14, 2019, Retrieved from https://www.uptodate.com/contents/prescription-of-opioids-for-acute-pain-in-opioid-naive-patients
- ↑ [6]5. In Opioid Epidemic, States Intensify Prescription Drug Monitoring. (n.d.). Retrieved November 24, 2019, from https://www.govtech.com/policy/In-Opioid-Epidemic-States-Intensify-Prescription-Drug-Monitoring.html
- ↑ [7]5. In Opioid Epidemic, States Intensify Prescription Drug Monitoring. (n.d.). Retrieved November 24, 2019, from https://www.govtech.com/policy/In-Opioid-Epidemic-States-Intensify-Prescription-Drug-Monitoring.html
- ↑ [1]Loudlow, R. (n.d.). State to enforce “safety checkpoints” on prescription opioid use—News—The Columbus Dispatch—Columbus, OH. Retrieved November 24, 2019, from https://www.dispatch.com/news/20180502/state-to-enforce-safety-checkpoints-on-prescription-opioid-use