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Washington Declares War on Opioid Epidemic, Fraudulent Doctors

August 7, 2017
To help put these announcements in perspective, Practical Pain Management spoke with 3 experts to tone down the rhetoric and to reassure physicians (and pain patients) about proper opioid prescribing practices.

Interviews with Jeffrey Fudin, BS, PharmD, FCCP, FASHP,  Forest Tennant, MD, DrPH, and Jennifer Bolen, JD

The US war on the opioid epidemic is heating up, with 3 recent noteworthy developments.

The opioid abuse epidemic has overshadowed the needs of legitimate pain patients, threatening proper pain care.

On July 31, Chris Christie, chair of the President's Commission on Combating Drug Addiction and the Opioid Crisis, issued his interim report, calling the recommendation to declare the opioid epidemic a national emergency the most important of all. (Among the other recommendations: mandating physician education, increasing availability of the overdose reversal agent naloxone).1

Meanwhile, Attorney General Jeff Sessions is vowing to go after doctors who commit fraud in prescribing opioid medications. He announced the creation of a special Department of Justice unit to target physicians and pharmacists who illegally dispense opioid painkillers.2

And on August 3, Jerome Adams, MD, a long-time advocate of the war on the opioid epidemic, was confirmed by the Senate as the new surgeon general.3

[Editor's Note: On August 8, US Department of Health and Human Services  Secretary Tom Price, MD, said the Trump administration could effectively battle opioid abuse without declaring it an official national emergency, seemingly contradicting the statement released on July 31. In a press conference reported by Medscape, Dr. Price said "we believe at this point that the resources we need or the focus we need to bring to bear on the opioid crisis can be addressed without a declaration of emergency, but all things are on the table for the president." Two days later, President Trump declared the opioid crisis a "national emergency."]

With this increasing focus on slowing the epidemic and prosecuting doctors and pharmacists who commit fraud, pain specialists and other physicians who treat chronic pain patients find themselves on the usual seesaw: how to follow good medical practices while caring effectively for their patients who need relief from chronic, unrelenting pain.

Practical Pain Management asked 3 experts to share their insights on how physicians can best accomplish that now and thrive in the current climate.

To follow are their best suggestions:

Review CDC Guidelines

Reviewing the CDC guideline for prescribing opioids for chronic pain is a crucial first step, says Forest Tennant, MD, DrPH, editor-in-chief of Practical Pain Management journal and an internist and addictionologist at the Veract Intractable Pain Clinics in West Covina, Ca.

Chief among those is to use the lowest effective dose and to ''carefully reassess evidence of individual benefits and risks'' when considering increasing dosage to 50 or more morphone milligram equivalents (MME) per day and avoid increasing to beyond 90 MME/day.4

He points out that the guidelines are meant to be used in a primary care setting and are addressed to physicians who do not specialize in pain treatment. For primary care doctors, Dr. Tennant says, the best advice is to stay within those guidelines ''or be working in tandem with a pain specialist who would help oversee a case that would need a higher dose of opioids."

Refer to the WHO Three-Step Ladder

In 2008, the World Health Organization (WHO) Steering Group on Pain Guidelines adopted its guidelines on treatment of chronic non-malignant pain in adults. (Other documents address malignant chronic pain in adults and chronic pain in children.)5

This document is as vital to review as the CDC guideline, Dr. Tennant says. He advises physicians to review the concept of a 3-step ladder, beginning with non-drug solutions and progressing first to weak opioids if needed. Stronger opioids are the third step, only after the first 3 steps on the ladder have not provided sufficient pain relief, Dr. Tennant says.

The ladder concept got dismissed, he says, as physicians began to prescribe stronger opioids as first line treatments. The WHO concept should never have been ignored, Dr. Tennant says.

Review State Guidelines

The news from Washington should motivate physicians to update themselves, says Jeffrey Fudin, BS, PharmD, FCCP, FASHP, owner and managing editor of PainDr.com and Pain Blog. He is also founder and chair of PROMPT (Professionals for Rational Opioid Monitoring & Pharmacotherapy).

Step 1, he says, is to be aware of the guidelines in your own state and to remember that ''they are only guidelines." However, ''there are certain states that do have mandatory cutoffs, hard cutoffs." These include Washington, Maine, and Massachusetts, he says.

The American Academy of Pain Medicine posts state legislative updates.6

Assess Your Patient Thoroughly

Besides addressing your patient's pain severity, it's crucial to evaluate and consider which patients are at higher risk of abuse, Dr. Fudin says. "In patients who are at higher risk [of abuse], doctors should be considering [prescribing] naloxone with the opioid," he says.

It's akin to giving a person allergic to bee stings epinephrine, he says.

Physicians should also do a full assessment for opioid-induced respiratory depression, Dr. Fudin says.

He points doctors to a validated tool, the Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD). He suspects few doctors use this, but says they should. It gathers information such as patient history for pulmonary disease or other chronic disease, use of antidepressants and other medications, current opioid dose, recent hospitalizations, and then calculates the probability of a respiratory depression induced by the medication.7

Educate Patients About Their Role

Efforts to curb opioid issues don't just lie with the physician and the pharmacists, says Jennifer Bolen, JD, founder of the Legal Side of Pain and a Knoxville, Tennessee, legal pain management advocate. "The patient has a huge component of responsibility," she says.

''Good prescribers and good patients must stand up and say 'I know the boundaries,'' she says.

She says that physicians might consider asking patients: "Are you using this [opioid] medication to feel better today or because you need it [for pain]?''

Having patients sign an opioid agreement is an option, Dr. Fudin says. Opioid agreements might include information about monitoring with drug screens, for instance. If an agreement has that, doctors need to actually follow up on the monitoring as agreed, he says.

Document, Document, Document

All 3 experts used 1 word frequently: document.

Documenting in the medical record won't make physicians and pharmacists bullet-proof, but it will go a long way towards protection should litigation occur, they agree. Exquisite documentation, Dr. Fudin says, makes it ''very very difficult for someone to hold them [doctors] accountable unless they are doing something illegal."

Documentation should include not just the medication and dose, medical history, and risk of respiratory depression but also the doctor's efforts to encourage lifestyle changes such as eating better and exercising regularly to enhance pain relief, Dr. Fudin says. And if a patient refuses those suggestions, document that, too, he says.

Consider Long-Term Solutions & Perspectives

According to Dr. Tennant, public health officials should consider creating a special certification for physicians who are pain management specialists. They could focus on the patients who need higher-than-typical doses of opioids, serving as the specialists called in when their expertise is needed.

Physicians concerned about avoiding litigation should focus on keeping their ego in check, Ms. Bolen says. She suggests physicians re-read their state guidelines to stay up to date and to consider documentation of patient details to be their job, not the task of someone in their office.

Dr. Fudin reports that he is a consultant, and on the speakers' bureau or advisory board for Astra Zeneca, Clarity, Collegium, Daiichi Sankyo, DepoMed, Egalet, Endo, Iroko Pharmaceuticals, Pernix Therapeutics, and is the owner of Remitigate, LLC.

Dr. Tennant is on the speakers' bureau for Regenesis Biomedical and INSY Pharmaceutical.

Ms. Bolen disclosed no relevant conflicts of interests to report.


Last updated on: August 14, 2017
Continue Reading:
Trump Orders Commission to Examine Opioid Addiction

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