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10 Ways Physicians Can Help Curb the Opioid Crisis

October 08, 2018

10 Ways Physicians Can Help Curb the Opioid Crisis

By Debra Wood, contributor

More than 115 people die each day in the United States from an opioid overdose, an issue the federal government calls an opioid crisis. Multiple factors have contributed — everything from prescribing at greater rates to patient diversion and misuse.

“This is a complex problem with complex origins,” said Edward Michna, MD, an American Pain Society board member and anesthesiologist and pain specialist at Brigham and Women's Hospital in Boston.

Michael D. McGee, MD, chief medical officer at The Haven at Pismo in Avila Beach, California, called the opioid epidemic a “wicked problem,” which has a formal definition of multiple contributing factors that cannot be solved easily.

“The solution will have to be through multiple, different dimensions over a sustained period of time to address the problem,” McGee said.

The National Institute on Drug Abuse reports from 21 percent to 29 percent of people prescribed opioids misuse them and from 8 percent to 12 percent develop an opioid use disorder.

“Physicians need to be aware of the risk, and let patients know it could damage their life,” McGee added. “That gives us pause before prescribing opioids. There are equally good ways to manage pain without narcotics.”

A positive trend toward fewer opioid prescriptions

The number of opioid prescriptions being written has declined 22.2 percent from 2013 to 2017, according to the American Medical Association (AMA), with a 9 percent drop occurring from 2016 to 2017. Providers wrote 196 million opioid prescriptions in 2017, down from 251.8 million in 2013.

The 2018 Survey of America’s Physicians, conducted by Merritt Hawkins on behalf of The Physician’s Foundation, confirmed this trend; 69 percent of the physicians surveyed reported writing fewer prescriptions for pain medications in light of the opioid crisis.

Physicians, nurse practitioners and others with prescriptive authority must take a proactive stance in order to keep this trend headed in the right direction, while addressing other factors that have led to the country’s current crisis.

10 ways clinicians can play a role in curbing the opioid epidemic

1. Follow the guidelines for chronic pain

The Centers for Disease Control and Prevention (CDC) reports that in 2016, 50 million U.S. adults, or 20.4 percent, suffered from chronic pain; 19.6 million, or 8 percent, had high-impact chronic pain, defined as pain that limits life or work activities.

The CDC issued guidelines for managing chronic pain, which call for nonpharmaceutical treatments and non-opioid pharmaceuticals before considering an opioid.

Other professional and accreditation organizations also have issued guidelines, including the American Academy of Pain Medicine, the Departments of Veterans Affairs and Defense, and The Joint Commission, which suggests behavioral approaches, environmental interventions, physical interventions, and non-opioid pharmaceuticals.  

“Individualize care, look at the situation and utilize all of the potential non-opioid therapies to try to help with improving the pain,” Michna said. “Alternative therapies should always be part of the therapy, whether opioids are involved or not.”

2. Evaluate and monitor patients thoroughly

“The whole thing starts with appropriate evaluation of the patient and monitoring the patient, and for acute problems getting the patient off [opioids],” Michna said. “There are varying tools you can use. Look at the history. Talk to the patient. Ask the questions.”

3. Check the databases

Use the prescription drug-monitoring program in your state. More than 1.5 million physicians and other prescribers have registered for the programs nationwide and they made more than 300.4 million queries in 2017, representing a 121 percent increase from 2016. 

4. Increase access to naloxone

The AMA, the American Academy of Family Physicians (AAFP), and other professional groups recommend increasing access to naloxone, which can be used to reverse the effects of opioids.

5. Enhance your education

The AMA also urges physicians to learn more about opioid prescribing, pain management, and screening for substance use disorders.

“Physicians need to become much more expert in pain management,” McGee said. “They need to know about multimodal, nonnarcotic ways of managing pain.” Those things, he said, include pain-modulating strategies to increase the pain threshold, relaxation, mindfulness, acceptance, positive thinking and other strategies.

McGee recommends licensing boards require education in pain management for relicensure.

6. Refer patients to pain management experts

Some patients will benefit from a referral to a pain management practice, which offers a multimodal approach to treatment, including behavioral therapy and teaching patients to learn to live with it, McGee said.

“There is a social or cultural aspect to this,” McGee said. “We live in a discomfort-phobic society.”

McGee suggested collaborating with experts in the psychological management of pain and helping patients shift from distress intolerance to making the best of life, even with pain.

“Acceptance is huge,” he said. “Learning to live with it. If we did that, think how much happier we would be as a culture.”

7. Support greater access to treatment

More physicians are being certified to provide buprenorphine treatment, 50,000 currently. The AMA encourages payers to cover medication-assisted treatment.

A study from researchers at Virginia Commonwealth University in Richmond, Virginia, found that early-care family physicians do not feel they are properly trained to provide buprenorphine treatment for opioid use disorder.

The U.S. Senate’s Opioid Crisis Response Act of 2018 (S.2680) would allow states to receive Medicaid matching funds from the federal government for services associated with opioid or cocaine use disorders.

8. Support coverage for non-opioid pain care

While multiple studies show that acupuncture, physical therapy and other integrative therapies can relieve pain, many health insurers do not cover these treatments. The AMA encourages payers to change policies to increase access to these treatments.

“If insurance does not pay, you can recommend [nonpharmacuetical therapies] all you want, but it’s not going to happen,” Michna said. “Insurance companies incentivize opioids.”

McGee added, “If we really wanted to address this epidemic, we would have a national initiative to get insurers to cover complementary and alternative treatments for pain.”

9. Stay abreast of new medications and rules

Many researchers are working to develop new types of pain medications. The recently passed Senate bill—lauded as a significant legislative achievement and “a rare bipartisan response to a public health crisis” by The Washington Post—aims to fast-track new, nonaddictive analgesics.

The Centers for Medicare & Medicaid Services plans on limiting first-time opioid prescriptions to a 7-day supply for patients with acute pain. Additionally, the U.S. Food and Drug Administration approved the final Opioid Analgesic Risk Evaluation and Mitigation Strategy, expanding it to include immediate release opioids in the outpatient setting.  

10. Help change perceptions and the stigma

The AMA states, “Patients with pain or substance use disorders deserve the same care and compassion as any other patient with a chronic medical condition.”

“We must all confront the intangible and often devastating effects of stigma,” explained Patrice A. Harris, MD, AMA president-elect and chair of the AMA Opioid Task Force, in a recent article for AMA Wire. “The key to recovery is support and compassion. Patients in pain and patients with a substance-use disorder need comprehensive treatment, not judgment.”

Additional resources:

HEAL Initiative (Helping End Addiction Long-term) - NIH

Reversing the Opioid Epidemic - AMA

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