Providers tackle opioid addiction with new policies, mindsets
Gov. Charlie Baker has made the state’s opioid crisis a top item on the agenda for his new administration. But it’s the providers who are taking on the brunt of that work.
Even before Baker announced on Feb. 5 the formation of a working group to devise a plan to curb opioid addictions – a problem that has long plagued the Northeast but came to a head last year –health care leaders had rolled up their sleeves to devise new policies to confront the crisis.
One of the groups, the Massachusetts Hospital Association (MHA), announced a new policy for addressing the misuse of opioid prescriptions in the emergency room, the same day Baker announced the formation of the working group.
Screening for addiction
The first in a three-phased approach, the policy emphasizes screening patients for opioid abuse while limiting the length of an opioid prescription to just a few days rather than weeks and avoiding prescriptions for long-acting opioid medications in favor of short-acting drugs to treat acute pain.
The challenge is that it’s not easy to discern who is an abuser and who has a true need for pain relief, said Dr. Art Russo, vice president of medical affairs at Harrington HealthCare, which has emergency rooms in Southbridge and Webster. Conditions that cause pain, especially back pain, don’t always provide visual evidence of a patient’s symptoms. Also, opioid abusers include people from all backgrounds, from professionals to people living on the street, he said.
“You have to be sure that you’re dealing with a true emergent situation as opposed to someone with drug-seeking behavior,” said Russo, a member of the MHA task force that drafted the new ER protocol.
Next, the MHA will draft protocols for providers working in hospital inpatient and ambulatory settings, and finally for primary care doctors who work outside the hospital. Russo said the MHA task force will probably work on this second phase for 60 to 90 days, while the third phase will require participation from health care stakeholders outside the MHA, and could take much longer to roll out.
MMS leader calls for better drug monitoring
Representing physicians who will be involved in Phase 3, Dr. Richard Pieters, president of the Massachusetts Medical Society, has called for a well-run, real-time, robust” prescription-monitoring program, which he said in a blog post is a “key element in the fight against prescription abuse and one in which every physician should participate.”
The state’s prescription-monitoring system allows providers to screen for patients who are shopping around for prescriptions from multiple providers. It has existed since the early 1990s, but the state made participation mandatory last year for providers who write opioid prescriptions.
The system has shortcomings. Pieters and others, including Attorney General Maura Healey, have advocated for better integration of the system, increasing state funding and allowing for interstate operability. Pieters also noted that pharmacist participation is not yet mandatory.
“It needs to include everybody,” Pieters said.
How did we get here?
While the level of opioid overdoses came to a head in 2014, prompting then-governor Deval Patrick to proclaim an epidemic, the problem had been brewing for years. According to state data, the number of unintentional fatal overdoses per 100,000 Massachusetts residents had an average annual increase of about 8 percent from 2000 to 2006 and remained steady until 2011. In 2012, the number of unintentional opioid overdoses jumped to 10 percent over the previous year, to 668.
Most of these overdoses occurred in heroin users, and public health experts agree many of those users first got hooked on opioids in pill form, prescribed by doctors.
Dr. Tony Dodek, associate chief medical officer at Blue Cross Blue Shield of Massachusetts, explained that medical training is at least partially responsible for the large amount of opioid prescriptions in Americans’ medicine cabinets and on the streets. Until recently, pain has been treated as a vital sign within a patient and it was considered bad medicine not to treat pain to the fullest extent, Dodek said.
In addition, Dodek said doctors are trained to order 30-day prescriptions so patients need fewer refills, minimizing inconvenience to both the doctor and patients. A prescription of this length has more time to create a habit in a user than a shorter course of pills does, and extra pills the patient doesn’t fill are more likely to hang around in the medicine cabinet, potentially falling into the hands of a family member, creating a risk in particular for adolescents.
“We think this is what fed into the heroin epidemic,” Dodek said.
Baker calls on insurers too
Insurers have also been called on to help stamp out opioid addiction. Baker held Blue Cross Blue Shield of Massachusetts up as an example for other insurers to follow, after the company implemented its own protocol for prescribing opioids in 2012.
To cut the high rate of opioid prescription claims, Blue Cross, the state’s largest private insurer, now limits the course of initial opioid prescriptions to 15 days for its members, and requires doctors to submit written authorization to a pharmacy after two courses.
Doctors prescribing opioids for chronic pain are also subject to new requirements, including drafting a care management plan and establishing a provider contract, which means members can only obtain opioids from one provider at a time. This limits their ability to shop around for opioids from multiple providers. Dodek noted that Blue Cross’ policy makes exceptions for cancer patients and the terminally ill.
So far, Dodek said the company has received just one complaint about the new requirements, which Blue Cross says has eliminated 9.6 million opioid-based doses from the community it serves.
“Those are kind of standard-of-care things that doctors should do whenever prescribing, so it wasn’t controversial among the medical community,” Dodek said.
Image source: Freedigitalphotos.net
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