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Prescribing Opioids: How New Policies Are Affecting Medical Specialties

Learn how emergency room physicians, dentists, rheumatologists, and orthopedic surgeons are dealing with new regulations and guidelines for pain management.
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The opioid abuse epidemic continues to dominate the news as celebrities die from overdoses, and federal and state agencies try to stem the tide of addiction and abuse. The Centers for Disease Control and Prevention (CDC) has issued new guidelines1; the Food and Drug Administration (FDA) has announced new safety labels2; President Obama signed the Comprehensive Addiction Recovery Act (CARA) aimed at addressing the pressing concerns of heroin and prescription drug abuse3; and, the National Governors Association has promised to create a set of protocols for dispensing opioids. Along with these developments, medical facilities and professional organizations are adopting new policies and procedures to help address the crisis.

When considering which doctors are most likely to be affected by these changes, the most obvious physicians are pain management specialists and oncologists, who routinely treat severe or unrelenting pain. However, pain management is an essential part of many other practices as well, including emergency room medicine, rheumatology, orthopedics, and even dentistry. While pain may not be their primary focus, these specialists are likely to encounter it as a common complaint every day, with opioids often included in their treatment toolkits. 

How are these medical professionals, whose patients experience varying levels of both acute and chronic pain, adapting to new guidelines and the pressures to reduce opioid use while still keeping patients’ pain at bay?

Emergency Medicine

Few specialists encounter more kinds of pain than emergency department (ED) physicians. ED doctors see it all, whether it’s a gunshot wound, a kidney stone, an auto accident, or an acute exacerbation of a chronic pain condition. Whether or not to prescribe opioids is a decision they face daily.

The American College of Emergency Physicians (ACEP) noted that the “primary goal of emergency care is to alleviate pain quickly, safely, effectively, and compassionately.” While opioids remain vital analgesic tools in this effort, heightened awareness of the dangers they pose, along with the new CDC guidelines, mean ED doctors face difficult decisions. “You want to provide pain relief, but you don’t want to start someone on the trajectory towards disaster,” said Lewis S. Nelson, MD, professor and chair of emergency medicine at Rutgers New Jersey Medical School, and a Core Expert Group member of the CDC guidelines task force.

The most challenging situation for ED doctors is the patient who arrives in the emergency room with an acute exacerbation of chronic pain. These patients suffer from a variety of conditions, including herniated discs, osteoarthritis, and migraines. (See related story.)

The goal with managing chronic pain in the ED is to return the patient’s pain level to baseline, not remove it altogether or fix the underlying cause, said Christopher Hogrefe, MD, assistant professor of emergency medicine and orthopedic surgery at Northwestern University Feinberg School of Medicine.

Many patients who take opioids regularly for their chronic pain are often asked to sign patient-provider agreements (PPAs), stating that they will consult their long-term pain management provider instead of heading immediately to the ED for pain relief. When such patients do request care at an ED, “we would attempt to contact the primary provider, who often expresses their dissatisfaction that the patient did not call them first,” said Dr. Nelson. “On occasion, in concert with the primary provider, we may medicate the patient in the ED with close follow-up by the primary.”

Whatever brings a patient to the emergency room, doctors are becoming increasingly cautious about using opioids. Dr. Hogrefe tells his medical residents that prescribing opioids in these cases is like fishing with dynamite: “You catch a lot of fish, but you also make a lot of mess in the process.”

Over time, opioids may even worsen pain, defeating their own purpose and triggering a vicious cycle. Even a small dose may lead to “tolerance and hyperalgesia, which leads to increasing the dosage, which leads to more tolerance and more hyperalgesia,” then on to dependence and, too often, addiction, said Dr. Nelson.

There are few decisions that Dr. Nelson takes more seriously than whether or not to prescribe an opioid. While he encounters many cases in the ED in which opioids are clearly the best option, he thinks long and hard about situations where the patient is in pain, but not enough to warrant such powerful and potentially addictive medications.

“I conduct a risk analysis every time I consider an opioid. I’d rather [the patient] experience a slightly higher pain score than take the 3% or 4% risk that” the patient may become dependent, he said.

When it comes to reducing reliance on opioids, another challenge physicians face is the patient satisfaction survey, which can affect both the individual doctor and hospital reimbursement. Surveys often ask patients to rate how well their pain was treated, which puts pressure on the physician to eliminate it quickly—something only opioids can do. “There are all these perverse incentives to overmedicate patients,” says Dr. Nelson.

Increased awareness of how surveys may encourage opioid prescribing has led some institutions to rephrase or eliminate questions related to pain. When opioids are prescribed, doctors are making a greater effort to inform their patients about the proper use of these medications, the risks they pose, and the right way to dispose of any leftover pills.

Drug Seekers and the ED

Drug seekers are a common problem in emergency rooms. “I think anyone who’s worked in the ED has encountered drug seeking” behavior, said Dr. Hogrefe.

ED physicians and others who suspect a patient is trying to satisfy a drug habit can turn to their state-run prescription drug monitoring program (PDMP). The PDMP shows when individual patients filled their prescriptions and if they have multiple opioid prescriptions on file. While the PDMP is a valuable tool, updates have a lag time of several days.

Last updated on: September 15, 2016
First published on: September 1, 2016
Continue Reading:
Moving Toward an (Almost) Opioid-Free Emergency Department

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1 comment.

By drstephenrodrigues on 10/07/2016
It has taken me 33 years to figure out that the fundamentals of health care and how doctors fight disease was broken 60 years ago. The authors of Medicare left out the first four fundamentals which could mitigate and almost eliminate many of the top 10 causes of death. Everyone knows that the policies and procedures embedded in Medicare rule everything that we do. The authors left out 1. education, 2. prevention, meaning teaching 3. assistance and 4. Physical Medicine and Rehabilitation. These are all the principles which will help fight diseases before the seed into the body. The #4 PM&R category of treatments are the only options to treat physical pain and misery!! This is Myofascial Pain and Dysfunctions. BUT, MF pain and the idea of Trigger Points have corrupted all of the critical facts needed to understand this pain pathology. Most all of the definitions and constructs are mixed up with poor imagery and mythologies. Muscles full of microscars drive pain signals. Muscles full of microscars drive muscle tissues to falter and fail. Muscles full of microscars drive secondary and tertiary findings. Muscles full of microscars make up all of the various TrP theories. TrPs do not drive all of the pain signals. The muscle system diseases are where the multitude of office based very odd and complex problems are sourced and located. Going back into the archives of PM&R and PT therapeutics before Medicare started to be so stringently enforced, physicians knew for certain that physical pain and misery was easily and effectively treated with physical therapy. This simple cause-effect, problem-solution is so easily overlooked because most all of it is invisible. Physical pain and dysfunction are treated with PM&R+PT. So while everyone is busy following Medicare policies and procedures we forgot to look, talk and touch our patients. Muscles can only heal from the inside by the natural forces from within. Medications or surgery cannot reach this pathology of pain. This is the reason why back surgery, hip surgery, shoulder surgery, knee surgery, carpal tunnel surgery, thoracic outlet surgery all do not work. This is the reason why many physicians to give out terms of opium derivatives to treat pain. You can't touch the pathology of muscle derive pain with any chemical. No matter how much you give are try. In the archives, one can review muscle pathologies and pathogenesis of disease that as muscle microscars increase in densities so does the signs and symptoms, so neuropathic pain, CRPS, and TN are all long-standing untreated muscle-derived pain and dysfunction. Healthcare will fail, Wall Street will fail if our leaders do not reinstate the full forces and spectrums of physical medicine and rehabilitation. Oh, by the way, acupuncture-needles, not so must the Chinese art, the tools are the primary key which will unlock the healing deeply embedded in muscle tissues. In this construct, a needle is a needle. A thin needle is not a hypodermic needle they are two different instruments. The hypodermic needle is the most potent ignitors of healing. Did you know that the FDA still considers Acupuncture experimental and investigational and is not a covered Medicare benefit to the elderly??!! What I have discovered in the Archives of PM&R and PT therapeutics is these treatment regimens always work. This is because there is a natural and innate guaranteed of workings. As long as the providers are free to customize the regime and the patient is free to orchestrate and guide the treatment processes. Mother Nature does all of the rest! Just like nature intended healing to be!