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Creating guidelines: Opioid prescribing in family practice

Rubin W. Hirsch, MD

ProHealth Physicians, CT

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ProHealth Physicians, part of OptumCare, is a physician-led health group caring for more than 345,000 patients with 350 primary and specialty care providers at 85 locations in Connecticut.

No single factor alone caused the dramatic rise in opioid use in America over the last two decades. 

That said, the number of prescriptions written by physicians and advanced practitioners for the two most common prescription opioid painkillers, oxycodone and hydrocodone, has spiked from seventy-six million in 1991 to 207 million in 2013.1

Morbidity and mortality from use of the drug has seen an equal surge. This complex epidemic facing the United States is front of mind for family practitioners. ProHealth physicians have been at the forefront of safer, more effective prescribing.

Growing awareness

Early in 2012, ProHealth took note of several Connecticut physician arrests for criminal overprescribing. Although none of the accused doctors were with ProHealth Physicians, these events prompted analysis of practices related to opioids. 

Presciently, then ProHealth Physicians Chairman Dr. Todd Staub warned that overprescribing, “Would soon surface as a nationwide problem.”

Assessing prescribing habits

Approaching the issue scientifically, ProHealth analyzed how providers were dealing with controlled substances. By using a survey that explained to providers that data gathered was explicitly for informative purposes, ProHealth gained a clear view of the prescribing habits of their providers.

The survey revealed doctor-to-doctor variance in rates of prescribing. Analysis of the data indicated an absence of uniform procedure for prescribing opioids.

It is abundantly clear that a simple solution for the problem of chronic pain control was evasive. There is no single right answer. 

Scientific evidence for safe and effective treatment for chronic pain is still being developed, and in its absence, providers walk a tightrope of under prescribing, exposing patients to the debility of untreated pain, or overprescribing, risking adverse effects, diversion of drugs, and in extreme cases, death.2

With background collected from its assessment, and knowing the scope of the challenge, ProHealth worked to make writing opioid prescriptions for chronic pain a safer, more consistent experience for provider and patient. 

Strict policy mandates were rejected as non-starters for providers who must work with the complex and diverse needs of individual patients. Respect for autonomous practice and trust between medical leaders and providers, like the trust between providers and patients, is valued.

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Creating the guide

Sensitive to these issues, ProHealth looked to resources already developed for guidance. The 2012 publication of the Federation of State Medical Examiner Boards titled “Responsible Opioid Prescribing, A Clinicians Guide” proved to be an invaluable guide.3

Also useful was the U.S. Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy (REMS). REMS began in April 2011, as a program using pharmaceutical industry funding for development and educational dissemination of safe opioid prescribing practices.4

ProHealth used these resources to develop their own set of “Best practice guidelines” focusing on utilizing the initial visit to screen and evaluate patients, give patient education on the risks and benefits of therapy and obtain informed consent prior to prescribing. 

The critical need to treat for functional outcomes and not total cessation of pain was a key component of the guidelines. Using this document as a foundation they developed a program to educate providers on proper prescribing of controlled substances. Guidance on when to obtain specialty consultation and how to terminate therapy were included.

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Included in the document were specific “Guiding procedures” which described more concrete measures that individual prescribers could implement. Documentation included a provider-patient agreement outlining therapy risks, benefits, goals, and expectations.

Monitoring interventions, such as pre-check of the statewide controlled substance database, helped to inform providers of behavior that might be drug-seeking, as well as risks posed by prescriptions not disclosed during the assessment.

Prescribing not more than a thirty-day supply of narcotics per appointment and using a single prescriber and pharmacy, are concrete measures intended to improve patient health and safety.

Conclusion

In the five years since ProHealth took up the challenge of creating a uniform and effective program of opioid prescribing, the U.S. opioid epidemic has indeed boiled over into a national emergency. 

The contributors to the crisis are many. In its foresight, with a dedication to patient safety, ProHealth laid the groundwork for pain management that relieves pain and improves function.

By focusing on the use of controlled substances to improve patient health and safety, providers can tailor their treatment for each specific patient yet remain within accepted practice guidelines. 

Adoption of these “Best Practice Guidelines” has resulted in a more uniform and standard approach to prescribing controlled substances at ProHealth Physicians. Providers and staff feel comfortable with a policy that acts as an objective backstop to their independent practice decisions.

With a structure that does not compromise the provider-patient relationship, but monitors safety and efficacy, the ProHealth opioid management best practice guidelines give physicians helpful tools, and patients better care.

 

The views and opinions expressed herein are those of the authors and do not necessarily represent the views of OptumCare. The views and opinions expressed may change without notice. 

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References:

  1. Volkow, N. D. (2014). America’s addiction to opioids: heroin and prescription drug abuse. Senate Caucus on International Narcotics Control, 14.
  2. Alford, D. P. (2016). Opioid prescribing for chronic pain—Achieving the right balance through education. New England Journal of Medicine, 374(4), 301-303.
  3. Fishman, S. (2012). Responsible opioid prescribing: a clinician's guide. Waterford Life Sciences.
  4. Alford, D. P. (2016). Opioid prescribing for chronic pain—Achieving the right balance through education. New England Journal of Medicine, 374(4), 301-303.