Supporting Appropriate Opioid Prescribing

The scope of the opioid epidemic is clear and has been addressed by several other previous posts including How the Opioid Crisis Stretches into Post-Acute Care, Treating the Opioid Epidemic, and A Roadmap to Fighting the Opioid Epidemic. This piece aims to offer 3 approaches that can be used in tandem to contribute to a solution.

1. Building processes that support appropriate prescribing of opioids
2. Amending provider prescribing habits
3. Passing legislation supporting best practices in opioid prescribing

Building Processes that Support Appropriate Prescribing of Opioids

Building processes that support appropriate opioid prescribing includes incorporating “soft” tools like shared-decision making and co-care management, as well as technical tools like amendments to EMR workflow and use of a Prescription Drug Monitoring Program (PDMP).

In an OB-GYN unit, employing a shared-decision making model when determining the prescription of opioids to patients after a C-Section has halved the median number of oxycodone tablets women chose to receive versus the institutional standard of 40 tablets.¹ This shared decision making model is spreading slowly as it is more easily adopted by medical specialties where physicians and patients are able to build rapport- such as in OB-GYN compared to acute surgery.

Whereas, in surgery, co-care models are emerging. Co-care refers to medical practitioners collaborating to enhance coordinated care for at-risk patients, such as the elderly. For instance, there are some centers that provide a co-care management model for geriatric patients undergoing surgery, where the surgeon and geriatrician manage the patient’s pre- and post-operative efforts to optimize care and reduce avoidable complications.²  In this model, the geriatrician maintains a central role in the care of the patient and makes recommendations on medication and pain control. This is particularly important in at-risk patients like the elderly, where the risk of delirium post-surgery is heightened.

In addition to or in conjunction with new models of care, system and technological tools can support appropriate opioid prescribing. In the Emergency Department (ED), if health systems set the expectation that patients presenting with severe pain receive Dilaudid (Hydromorphone), then it becomes easy for narcotic seekers to manipulate and abuse the healthcare ED system.

Forty-nine of fifty states provide Prescription Drug Monitoring Programs (PDMPs), which encourage or require patient information to be entered into the PDMP tracking system in order to see where, when and what type of other controlled substance prescriptions have been acquired by that patient. This allows potential narcotic seekers who may benefit from substance use disorder or addictions treatment, such as medication assisted treatment, to be identified and triaged for more appropriate care.

In fact, some EMR systems are configured to require an electronic signature and justification of an opioid prescription.  This safeguard is intended to enhance physician awareness and consciousness that they are prescribing an opioid. There are also a few institutions that have placed a cap on how many days a prescriber can prescribe opioids post discharge from the hospital. This cap on opioid supply requires a system change where the primary care physician follows up with the patient in an outpatient setting if additional opioid prescription refills are required. As the examples demonstrate, multi-systemic changes in process and structure must be enacted in conjunction with other efforts in order to support appropriate use of opioid prescriptions.

Amending Provider Prescribing Habits

Focusing on patient-centered care requires a dialogue with prescribers about pain tolerance, diagnosis, and treatment goals. These conversations coupled with provider education about best practices in opioid prescribing can amend prescribing habits. By treating acute pain conservatively and in alignment with treatment goals, providers can contribute to mitigating the opioid epidemic.

In a randomized clinical trial of 411 ED patients with acute pain, Chang et. al (2017) found no significant difference in pain control two hours after medication administration when patients were given either a single dose of opioids or non-opioid analgesics.³   In a practice environment, early findings suggest that NSAIDs with Acetaminophen are at least equally, if not more effective in treating acute pain than opioids. Patients who suffer from chronic pain once had acute pain that was not properly managed and instead evolved into chronic pain.

Often when pain is severe such as acute dental pain, prescribers have been quick to prescribe oxycodone, when in fact the acute pain should be first addressed with non-narcotic medications, including nonsteroidal anti-inflammatory drugs (NSAID)s and acetaminophen. Instead, providers often treat with a low-dose oxycodone (5 mg) as the first line therapy. This lowers the threshold of pain, causing stronger medications to be required if the pain persists.

In resolving the opioid crisis, a portion of the solution is addressing how acute pain is handled, including taking the time to discuss with patients risks and benefits of prolonged opioid use. Another aspect of the solution is educating or re-educating providers on guidelines and protocols around best practices for acute pain management.

For instance, educating different medical providers on the management of chronic low back pain will provide a standardized method of recognizing and treating the pain appropriately.  In fact, one of the first line treatments of lower back pain is weight loss, not opioids.  Therefore, provider and patient education on how to effectively and adequately manage pain may reduce the number of opioids prescribed and consumed daily.

Relias’ own research demonstrates that providing brief educational information about appropriate use of opioid medications, along with risk indicators of dependency or addiction, shapes prescribing habits at the point of care. This study demonstrated that this educational intervention, called audit and feedback, reduced inappropriate opioid prescriptions by an average of 27 percent.

As we continue to focus on patient-centered care, it is important to consider each patient’s unique needs. For example, a patient presents in the ED with acute pain and is flagged in the system with a substance use disorder. At first the blush, the initial recommendation, is to start the patient on NSAIDs/Acetaminophen. However, further exploration into the medical chart and patient interviews reveals that the patient was recently diagnosed with a terminal cancer.  Therefore, treating the patient with opioids to relieve the pain is appropriate, even though the patient has been flagged as a narcotic seeker. In this case, the risk benefit analysis weighed in favor of prescribing opioids.  It is important that we support appropriate use of opioids for proper indications of pain while deterring inappropriate use.

Additionally, front-line prescribers should discuss the patient’s pain tolerance. For example, in hospice patients, many often choose experiencing more pain instead of the wooziness that many opioids produce. A discussion of tolerance of pain is influenced by culture and patient goals, making this conversation especially important for providing patient-centered care.

Passing legislation Supporting Best Practices in Opioid Prescribing

In addition to changes to organizational processes and provider education to enhance patient centered care, combating the opioid epidemic will require legislative support of best practices in opioid prescribing.

In the past, after a surgery, 30-45 pills of oxycodone might have been prescribed. Now, many surgeons, often supported by state laws, are now starting with smaller prescriptions of 3- 7 days’ worth of pain pills so that patients must come back for a refill. Through this sort of legislation, leaders hope that there will be:

• A reduction in overprescribing
• An increase in follow-up with patients who have ongoing pain and require refills
• A reduction in drug diversion for unused opioids

By reducing the number of pills prescribed, prescribers may reduce the potential risk patients have in becoming narcotic seekers in the future. Not only is state legislation moving towards alignment with best practices in pain management, but grants are also moving in alignment to fund best practices in opioid prescribing.

Final Thoughts

When process, incentives and legislation are aligned, prescribers make the best choice, also the easy choice, and better outcomes result for all the patients we serve.

Interested in Learning More?

Relias helps healthcare organizations address the opioid crisis through data analytics and provider education. Our newly released Opioid Risk Solution assists with risk stratification for overdose, misuse and dependency, identifying and suggesting nonopioid alternatives for pain treatment and allows prescribers to view their own prescribing patterns compared to their peers along various dimensions of best practice. In tandem, Relias offers accredited opioid-specific continuing education to support best practices in opioid prescribing, pain management, and behavioral health and substance use treatments, such as Medication Assisted Treatment.

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Special thanks to Dr. Aladine Elsamadicy, Neurosurgery Resident at Yale-New Haven Hospital, for her contributions to this post.