Prescribing Opioids: How New Policies Are Affecting Medical Specialties
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?
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.