Raise the bar on pain management and opioids

With the end of the opioid/painkiller crisis nowhere in sight, it’s up to providers and facilities to lead the charge.

More than three dozen bills addressing various concerns about the opioid epidemic are before committees in the Senate and House. The Centers for Disease Control and Prevention (CDC) issued restrictive new guidelines for chronic-pain prescribing in March 2016, and the President’s Commission on Combating Drug Addiction and the Opioid Crisis was established a year later.

States, however, have been ahead of the feds, with many instituting tough prescribing and dispensing restrictions; for example, effective January 1, 2018, North Carolina’s STOP Act restricts acute-pain opioid prescription amounts to five days and postoperative opioid prescriptions to seven days.

In some cases, payers have reacted with their own restrictions. “Some insurance carriers are beginning to decline coverage for any opioids prescribed beyond the protocol recommended by the CDC,” says Nancy Irwin, PsyD, primary therapist at Seasons Recovery Centers in Malibu, California.

And hospitals can make their own policies, too. Institute a policy on opioid prescribing to relieve your providers of some decision-making pressure in an age of addiction awareness—and, if you do it right, your providers should still be able to give patients the pain relief they need.

Do more than bare minimum
It is, of course, important to keep up with the law, which can vary significantly from state to state. For example, in New York, all prescriptions, including those for controlled substances, must be electronically written except in emergencies, while in other states a paper prescription is required.

“We have to write out the scrips—can’t call it in at all,” says Barbara Bergin, MD, an orthopedic surgeon with Texas Orthopedics, Sports and Rehabilitation Associates in Austin, Texas. “We can call in Tylenol #3—which people who are habituated don’t like because it’s not strong enough for them. But anything stronger has to be written out on a prescription, which the patient has to hand deliver to the pharmacy.”

And in some states like New York, it’s the provider’s responsibility to keep tabs on their patients’ opioid prescription history via prescription drug monitoring programs (PDMP), says Kate Fuss, a surgical physician assistant most recently with hospitals in the Greenwich, Connecticut area.

In addition, revised pain management standards by The Joint Commission, effective January 1, include a new Leadership standard, LD.04.03.13, featuring an element of performance that requires hospital leadership to provide clinicians and pharmacists access to their state's PDMP.

Beyond whatever your state or local authority having jurisdiction requires, your policy on opioids is, to a great extent, your hospital's call, and experts suggest that you nail that policy down to protect both provider and patient.

Some prescribers have worked out their own ways of dealing with a patient whose PDMP record shows a recent opioid prescription. “Typically, I will prescribe them a third to a half of the original prescription I was going to write for [patients], as they do need appropriate pain coverage post-operatively,” says Fuss. “Typically, there is not much pushback.”

When she gets “pill-counting” behavior—that is, when patients specifically comment on how many pills they have and how many they think they need—“the encounter becomes slightly more complex,” she says. If she’s getting nowhere with the patient, she defers to a pain management specialist, either the patient’s own or one to whom she refers.

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