Opioid Prescription Control: When The Corrective Goes Too Far

Opioid Prescription Control: When The Corrective Goes Too Far  – Stefan G. Kertesz, Adam J. Gordon, Sally L. Satel – Jan 19, 2018

As a way to stem the harms associated with prescription opioids, many health care entities and state governments have imposed restrictions on opioid prescribing for acute and chronic pain, creating new problems that require both monitoring and remediation.

By mid-2017, 23 states had enacted legislation with a limit, guidance or requirement related to opioid prescriptions, according to a review by the National Conference of State Legislatures.

Most of these 23 states restrict prescription length based on the contested proposition that mandatory limits will prevent opioid addiction.

• The number of opioid prescriptions written by health care providers has fallen since 2011, and
• the number of high dose prescriptions (>90 MME) fell 41.4 percent from 2010 to 2015.

Chronic pain patients, who are stable and arguably benefiting from long-term opioids, are now facing draconian and often rapid dose reductions.

Sometimes, alternatives to opioids for chronic pain are not offered, not covered by healthcare insurers, or not readily accessible or available to patients.

Consequently, patients have endured not only unnecessary suffering, but some have turned to suicide, 23 of which are publicly documented by a physician. We worry that these tragedies, too, will escalate as opioids are restricted.

The new restrictions will almost surely accelerate this trend. But the move to encourage (and enforce) more conservative prescribing has produced unintended consequences.

Physicians often declare that involuntary prescribing changes are due to federal guidelines. Yet the Centers for Disease Control and Prevention (CDC) issued no mandate that physicians make abrupt or dramatic changes to care in its 2016 Guideline on Prescribing Opioids for Chronic Pain.

For patients already on opioids, the Guideline suggests that physicians and patients consider the potential harms and benefits of continuing opioids.

It makes no claims about the benefits of nonconsensual dose reduction, a practice for which supporting data do not exist.

The irony is that these developments are hurting people who are reasonably unlikely to misuse opioids, although opioids do present important safety concerns, including risk of overdose.

As federal and private survey data indicate, pain patients are not at highest risk for misuse of prescription opioids. Instead, most misuse reflects diversion.

Despite these realities, in today’s administrative climate all incentives point toward nonconsensual dose reductions, with little consideration for patient wellbeing.

an opioid quality metric that counts the number of patients receiving over 120 MME against the performance rating for a physician or other care provider.

And then we wonder why we cannot find physicians to treat our pain.

None of these metrics honor the CDC Guideline’s distinction between new opioid starts and follow-up care of patients already stable on a given dose. And none take into account whether patients live or die as a result of the care they receive.

Similarly, Prescription Drug Monitoring Databases, mandated in over 35 states, invite fear of prosecution. Most states do not require a warrant for law enforcement to search the data and recent Circuit Court rulings have overruled two that did.

As a result of these policies, clinicians feel caught between the demands of regulators and patients.

In a recent Medscape survey, half the doctors expressed fear of violent reactions from patients seeking prescriptions.

To alleviate the risk opioid discontinuations that lead to tragedy, we believe three things are necessary:

First, a more comprehensive system should monitor adverse outcomes associated with ending opioid treatment.

We consider the immense distress, the abandonment by her physician, and potential disaster of suicide that befell Dr. R when her methadone was discontinued to fall uncomfortably close to a sentinel event.

The Joint Commission defines a sentinel event to be a patient safety event that results in death, permanent harm or severe temporary harm. It mandates these events be analyzed, recorded, reported to the patient or family, and subject to corrective action.

Another post-hoc monitoring approach would enlist the investigative capacity of the CDC, which already dispatches trained investigators to assess outbreaks of diarrhea and poisonings.

Suicide rates are rising in the United States, and the CDC should investigate cases of suicide that ensue when stable patients in good standing (i.e., those who have not threatened staff, forged prescriptions, etc.) are non-consensually taken off opioid medication.

Second, contemporaneous data could help prevent harm and track risk to patients in real time.

Suicidal ideation and reports of its completion following opioid discontinuation increasingly find their way to Facebook, Twitter, and news article comments sections. Concerned laypersons already use social media to assist pain patients at risk of suicide.

In addition, investigators associated with integrated health systems and large insurers can and should use analytic techniques to capture both the frequency and risk factors for adverse outcomes, including death, following opioid discontinuation

Along these lines, health care providers that already monitor opioid prescribing should develop registries to record adverse outcomes such as overdose, hospitalization or death, after prescriptions end.

Finally, physicians require reaffirmation of a professional safe harbor for cautious, patient-centered decision-making where opioids are concerned

A tenet of medical practice dictates that if a patient is stable on a medicine, then any change must be accompanied by a good reason to do so.

Whether or not a patient was initially a good candidate for opioids, if they are now stable, then great care must be taken in any transition. For this reason, regulators should re-evaluate policies that incentivize dose reductions without reference to patient wellbeing.

Original article: Opioid Prescription Control: When The Corrective Goes Too Far