Tuesday, November 17, 2015

Why Aren't We Linking PDMPs and EHRs?

The development of prescription drug monitoring programs (PDMPs) nationwide is a necessary, albeit insufficient by itself, step in our fight against prescription drug misuse and abuse.  I've long advocated not just for mandatory reporting to PDMPs (which requires doctors and pharmacies to contribute data to the database) but also of mandatory use of the PDMP (by prescribing physicians prior to writing prescriptions for potentially dangerous medications).

Many physicians (and their associated lobbying groups) have pushed back on the notion of mandatory use of PDMPs based on three categories of objections:

First: "I don't get paid for this..."  Fair enough.  One could argue that a surgeon isn't explicitly paid to wash her hands prior to surgery and does so anyway because it's in the best interests of patient safety... though the reality is that our fee-for-service RVU-based system actually does pay the surgeon for that activity.  So I get this argument.  

Second: "The data isn't reliable... it's either not timely or not accurate..."  This is certainly an issue, though one that will resolve itself over time with proper funding and enforcement of reporting requirements.

Third: "The database access is inefficient, the technology isn't robust..."  Also an issue, but one that I think will resolve itself over time as critical mass develops around the need to exchange this data.

But what if we could fix all three issues in a single stroke of technological innovation?  

Ohio is doing just that.  Governor (and Republican presidential candidate) John Kasich is spending the necessary dollars (a whopping $1.5 million) to integrate Ohio's PDMP with the electronic health records systems of doctors, hospitals, and pharmacies.

This is genius.  

"The message to Ohioans, despite the fact that will still see a tsunami of drugs, is that we're not going to give up in this state until we win more and more battles, maybe ultimately the war," Kasich said at a news conference.

Why isn't every governor in the country working on this?  

On Twitter @PRIUM1

Monday, November 9, 2015

The Case for Physician Education in Light of Rising Death Rates

Two recent and related op-ed pieces in the NY Times lay out the logic I articulated in my last blog post on addiction and mental health.  The two pieces, taken together, offer a glimpse of the crushing reality of contemporary social and cultural circumstances for some population groups in this country as well as at least one clear imperative for how we might begin to fix it.  I don't have the bully pulpit of the Times editorial page (I wish), so I'm happy to defer to a Nobel prize winning economist and a professor from Cornell's medical school, respectively, to lay out this critical message to a much broader audience.

Paul Krugman (he's the Nobel prize winner) puts the recent research on rising death rates of white middle-aged Americans into political and economic context.  While he is a unapologetic liberal, his ultimate conclusion is that our politics didn't necessarily cause this despair, at least not in any direct sense.  Rather, the issues are more existential in nature.  One of the study's authors, Angus Deaton, offers a hypothesis: this group, he says, has "lost the narrative of their lives."  Krugman puts it in his own words this way: "we're looking at people who were raised to believe in the American Dream and are coping badly with its failure to come true."  And one of the most significant and negative coping mechanisms employed by this group?  Prescription painkillers.

Richard Friedman (he's the professor from Cornell medical school) builds a case for mandatory physician education for pain management and does so by building on the same Deaton-Case research from which Krugman's piece is derived.  He writes:
"All medical professional organizations should back mandated education about safe opioid treatment as a prerequisite for licensure and prescribing. At present, the American Academy of Family Physicians opposes such a measure because it could limit patient access to pain treatment with opioids, which I think is misguided. Don’t we want family doctors, who are significant prescribers of opioids, to learn about their limitations and dangers? 
It is physicians who, in large part, unleashed the current opioid epidemic with their promiscuous use of these drugs; we have a large responsibility to end it."
The more I read and write about chronic pain issues, the clearer it becomes to me that when we focus on root case issues, we increase the probability of making a dent in the problem.  This can be hard and depressing work, though.  Tracing chronic pain and drug abuse to root causes remains elusive - the answers are tied to social, cultural, economic, and historical forces we're just beginning to understand and unravel.

But one thing we must certainly do is ensure that the medical professionals charged with the health and well-being of their patients are, in fact, helping and not hurting our progress.

On Twitter @PRIUM1

Wednesday, November 4, 2015

Mental Health and Addiction: What if We Had What We Really Need?

Consider several seemingly unrelated articles that all ended up in my stack of "articles to read" just in the last three days:

First, a report from the Proceedings of the National Academy of Sciences that found that the death rate among white, middle-aged Americans has grown since the 1990s, while death rates among the same age cohort within other ethnicities and countries has continued to decline.  From the report: "Rising midlife mortality rates among non-Hispanics were paralleled by increases in midlife morbidity.  Self-reported declines in health, mental health, and ability to conduct activities of daily living, and increases in chronic pain and inability to work, as well as clinically measured deteriorations in liver function, all point to growing distress in this population."  The researchers speculated that relatively easy access to opioid pain killers may be linked to the rise in incidence of mental illness.  While I think they have the cause and effect backward, there's little doubt in my mind that the two are related.

Second, a report from WESH in Orlando on a US government study that estimates there are 4 million baby boomers struggling with addiction.  "Baby boomers," the group of Americans born within the 19 year period following WWII, are now in their 50s and 60s and they're suffering from drug and alcohol addiction at a rate that rehabilitation and recovery services cannot accommodate.  "It's hard to imagine grandma with a heroin problem," says Dr. Heather Luing, medical director at Recovery Village, "but that's the reality we sometimes see."

Third, there was a lot of international coverage of a controversial paper from the United Nations Office on Drugs and Crime (UNODC) that suggested UN-member countries should consider "decriminalizing drug possession for personal consumption."  The paper was retracted by UNODC leadership with an explanation that it was written by a mid-level policy person simply expressing a viewpoint and was never sanctioned or adopted as a formal UNODC position.  This public policy approach, however, has been tested, perhaps most notably in Portugal.  Despite warnings of potentially dire consequences, Portugal decriminalized the simple possession of all drugs back in 2001.  Since that time, Portugal has seen overall drug use fall, it has the second lowest overdose death rate in all of Europe, and HIV infections among drug users are dramatically lower,  The resources formerly focused on arresting and prosecuting simple drug possession were instead poured into mental and behavioral health, education, and job training/placement programs.  And if you think such a program wouldn't be possible in the US, check out what Worcester, MA is doing.  

What are the common themes here?

  1. People are dying.  That much is statistically evident.  
  2. These deaths appear to be correlated with chronic pain, drug use, mental illness, and addiction. 
  3. Efforts over the last three decades to deal with the issue from a criminal justice standpoint appear to be at least ineffective and at most counterproductive.  
  4. The current supply of mental and behavioral health resources in the US is nowhere near sufficient to meet demand.  

So if the demand is there, why don't we have the mental/behavioral health resources we need? Because we've never devoted the reimbursement dollars necessary, either public or private, to ensure such programs were economically viable.  But now, with the Affordable Care Act's parity provisions, we have legislatively mandated reimbursement policies around mental health coverage offered by private insurers.  The resources haven't yet caught up to the demand, but billions of dollars of private equity investment is being poured into the sector.  Hopefully, it's just a matter of time before the number of trained professionals and the facilities and technologies they need to practice are in place.

And that leads us to an interesting thought experiment: What if we did have the mental and behavioral health infrastructure we so desperately need? Could we fundamentally change how we approach drug abuse in our society?

On Twitter @PRIUM1

Tuesday, October 27, 2015

Low Back Pain: What's the Best Medication Approach?

Wouldn't it be great if there was a study that compared patient outcomes among several groups based on a single, common diagnosis but several potential medication regimens?  How might such a study be designed?

Perhaps you could identify 300 patients, all of whom presented in the emergency department of a hospital with acute low back pain.  We might assess their level of disability utilizing a widely used health status measure like, say, the Roland Morris Disability Questionnaire (RMDQ).  We might divide the patients into three groups based on their medication regimen:
1. Naproxen + placebo
2. Naproxen + cyclobenzaprine
3. Naproxen + oxycodone/acetaminophen

We'd make sure the initial RMDQ scores were roughly similar across all three groups.  We'd also make sure all three groups were similar demographically and that each patient received education on management of low back pain prior to discharge from the hospital.    Then we'd call the patients at the 1 week mark and the 3 month mark to re-assess their level of disability.  That would tell us which of the three various medication regimens provides for the best patient outcomes.

Such a study would be helpful, right?

Well, researchers at Montefiore Medical Center and Albert Einstein College of Medicine conducted just such a study and the results are compelling.

It appears that "take two Aleve and get some rest" may, in fact, be the best (and certainly the safest) course of action when it comes to preventing acute LBP from becoming chronic LBP.

On Twitter @PRIUM1

Tuesday, October 20, 2015

What Happens When Regulators Don't Trust Clinicians?

USA Today published an interesting point/counterpoint this week on the question of whether doctors should be forced to check a prescription drug monitoring database prior to writing a prescription for an opioid.  The advocates for such an approach (me included) argue that fundamental public health concerns trump the arguments against mandatory checks, primarily that this new step in the process of clinical delivery presents privacy and convenience hurdles.

But if one examines the true concerns of clinicians that have pushed back against mandatory PDMP checks, one would find a deeper, more meaningful, more consequential issue: when it comes to prescription drug misuse and abuse, government regulators are exhibiting ever higher levels of distrust of the medical community.   

Perhaps nowhere else has this been laid more plain than in Massachusetts.  Governor Charlie Baker, a former physician group and health plan CEO, has proposed an aggressive set of measures to stem the opioid epidemic in his state.  I'm not using the term "aggressive" lightly here...

Among several other potentially controversial provisions, the proposed bill would limit new prescriptions for opioids to 72 hours (with very limited exceptions for emergency situations).  A patient in Massachusetts might go to the doctor, complain of low back pain, and receive a script for pain management.  But the max a doctor would be able to write is a 3-day script.  After that, the patient would need to come back to the doctor for an additional script if the continuation of the medication is deemed necessary.

As expected, the reaction of Massachusetts doctors appears to range from supportive to skeptical to deeply concerned.

I haven't decided whether or not this is a good idea.  I'll be researching the approach and discussing it with others for a while before I come to any conclusions.

What strikes me is that regulatory bodies ranging from state work comp agencies (think "closed formularies") to state legislators (think "mandatory PDMP checks") to state governors (think "Charlie Baker's plan") are essentially saying: Enough of this.  It's gone on too long and too many people are dying.  The clinical community has had their chance.  It's time for us to step in and shut this down.

Will there be unintended consequences?  Yes.  Will it result in the mitigation of prescription drug misuse and abuse for which we all hope?  TBD.

Might the clinical community awake and recognize the necessity for them to self-correct this problem to avoid further unwelcome intrusion into clinical practice from the regulatory community?

I hope so.

On Twitter @PRIUM1

Wednesday, October 7, 2015

A Prescription for Preventing Overdose Deaths

I've been openly critical of the American Medical Association's approach to the opioid epidemic. I've labeled it "necessary, but insufficient" - meaning that the initial recommendation of the AMA's Opioid Abuse Task Force was to encourage physicians to register and use their state's prescription drug monitoring program (PDMP).

Politically safe.  Glaringly obvious.

In response to that blog post, several physicians reached out to me to express their frustration with the AMA.  One of PRIUM's physician consultants pointed out that AMA membership now represents a mere 15% of practicing physicians in the US.  I checked that stat and she's right.  AMA membership has been steadily declining since the 1950s, when nearly 75% of physicians belonged to the group. I'm beginning to understand why (though I'll admit the AMA's support for the Affordable Care Act and the rise of specialty physician associations has certainly contributed).

I did award points for the AMA's willingness to join the discussion and offer solutions.  I expressed hope that this was just the start and that we would see further, more aggressive measures among the future recommendations that the task force promised it would be making.

This week, the AMA Task Force has offered the next step: "With the United States in the midst of an opioid misuse, overdose, and death epidemic [emphasis added], the AMA Task Force to Reduce Opioid Abuse strongly encourages widespread access to naloxone as well as broad Good Samaritan protections to those who aid someone experiencing an overdose."

Politically safe.  Glaringly obvious.

We should all be advocating for increased access to naloxone, though I've focused my advocacy on providing the overdose antidote to first responders and care givers in high risk populations.  The concept of co-prescribing and physician standing orders (every script for an opioid comes with a script for naloxone) troubles me.  The AMA statement encourages doctors to ask the following questions when considering co-prescribing naloxone:

  • Is my patient on a high opioid dose?
  • Is my patient also on a benzodiazepine?  
  • Does my patient have a history of substance use disorder? 
  • Is there an underlying mental health condition?  
  • Does the patient have a co-morbid respiratory disease?
  • Might my patient be in a position to help someone who is at risk of overdose?
With the exception of that last question, this should represent the list of questions doctors ask themselves to determine whether they should continue to prescribe opioids at all (vs. considering whether to prescribe another drug to counteract the potentially disastrous side effects of the current medication regimen that is so obviously dangerous, the risk of overdose appears imminent).  

This latest set of necessary, helpful, but totally insufficient recommendations from the AMA helped me to recognize what I think is the fundamental issue with their approach: These recommendations are focused on how to deal with risks after the drugs are prescribed and dispensed.

So here's my challenge to the AMA: What can we do before the drugs are dispensed?  

On Twitter @PRIUM1

Tuesday, October 6, 2015

The Opposite of Addiction is Not Sobriety

At the close of the blogger panel in Dana Point last week, Mark Walls asked each of the panelists what we thought needed to change in workers' compensation.  There's a lot of potential material there, I know.  And my co-panelists - David DePaolo, Bob Wilson, and Tom Robinson - all offered great suggestions that included more meaningful engagement with injured workers and simplifying the system with the aim of focusing on what matters most.

I took the "personal soap box" approach to answering the question.  Here's what I said (actually, here's what I meant to say):

I think that we, in workers' compensation, will spend the next 10 years paying for the sins of the last 10 years.  While we may have a (slightly) better handle on medication management for new injuries today, we spent the last 10 years paying for too many drugs to be given to too many patients.  And, as a result, for the next 10 years, we're going to be looking straight into the abyss of addiction.  

We better learn how to deal with it because ignoring it is neither a clinical nor an economic option for payers.  Payers didn't write the prescriptions, but they did pay for them.  Resulting cases of dependence and addiction are natural extensions of medication treatment that long ago ceased to have any chance of resolving the underlying injury, but has instead led to a life (if you can call it that) completely consumed by the need for more drugs.

I don't have a silver bullet solution to offer here.  This is going to be hard and it's probably going to be expensive.  But if we do it right, as an industry, we can create models for how other systems (group health, municipalities, even countries) approach the issue.

Here's a place to start:
My colleague, Scott Yasko, sent out a TED talk on addiction that I found fascinating.  Leave the political questions aside for a moment (the speaker, Johann Hari, offers some interesting thoughts on decriminalization, but don't get distracted by that...) and focus instead on the underlying psychosocial argument he's making.  (I should also acknowledge that Hari has a checkered past as a journalist, but his thoughts here are well-researched and profound... and presumably his own).  If you stick with it until the end, you'll hear him conclude:

"The opposite of addiction is not sobriety.  The opposite of addiction is connection."  

Does that make you think differently about how we might approach the issue of addiction in workers' compensation?

On Twitter @PRIUM1

Tuesday, September 29, 2015

Safety is Just As Important After the Injury as Before the Injury

The National Safety Council is holding their annual Congress this week here in Atlanta.  Tuesday is the only day this week I'm actually in Atlanta, so I thought I'd check it out.

For those of you that have attended the NWCDC in Vegas each year, the expo hall at the National Safety Council Congress is every bit as impressive.  Lots of people, lots of educational sessions, lots of booths, lots of pitches.  The exhibitors here in Atlanta this week represent an interesting contrast to the typical booths we see at our work comp conferences.  Whereas a lot of the booths at our conferences are focused on the life of the worker after the injury, the National Safety Council appears to primarily attract companies and organizations focused on preventing the injury in the first place.  There are lots of apparel companies... fire retardant clothing, dozens of different shoe/boot companies, more companies selling gloves than I could have ever imagined... as well as safety equipment... ropes, ladders, harnesses, etc. to keep workers safe.

But I couldn't help but notice what wasn't represented on the exhibit floor.  The conclusion I drew from the menagerie of booths was that safety concerns apparently cease once an injury occurs.  Employers and insurers are assuming, incorrectly, that once a worker is injured and enters the medical system for treatment, that injured worker's safety is assured.  

That's simply not the case.  And we know better.  

In fact, our collective concern about injured worker safety needs to be just as focused, just as important, just as urgent as it was before the injury occurred.  

The National Safety Council is leading the way on this.  Dr. Don Teater and Tess Benham at the National Safety Council are working to leverage the brand and clout of their non-profit organization to help tackle the safety issues related to prescription drug misuse and abuse.  They're doing research, engaging employers, writing white papers, giving speeches, and working hard to bring attention to this issue.

I challenge you to check out the NSC's work on this topic (see the link in the previous paragraph) and to see if there's a way you can help advance the good work they're doing.  The NSC has been around a long time (100 years!) and they've worked on some of the biggest safety issues we've confronted as a society.  You know how your claims frequency is trending down, year after year, for the last 50 years?  Well, the NSC has played at least some small part in that through their work on driver safety, worker safety, fire safety, and other key areas.

Now they're tackling prescription drug misuse and abuse.  That's a wake up call for all us.  This is serious.  

On Twitter @PRIUM1

Thursday, September 24, 2015

Mandatory Education for Prescribers

Massachusetts Governor Charlie Baker and the deans of state's four medical schools are teaming up to educate medical school students about misuse and abuse of opioids.  Boston University, Tufts University, Harvard University, and the University of Mass. will collaborate to develop a curriculum around pain management that balances the need for pain relief with the risks of opioid addiction.  As far as I can tell, this effort is the first of its kind in the nation.

A week before this announcement from Mass., Dr. Douglas Grant, registrar of the college of Physicians and Surgeons of Nova Scotia, told a Canadian audience of doctors that physicians should be subject to mandatory continuing medical education in the appropriate prescribing of opioids.

"With respect to opioids, there's been in my view a general loss of awareness, a growing casual attitude about the risks of these medications," he said.  He also noted there's been a shift in expectations among patients to be not only treated for pain, but to be pain-free.  "That's created a positive feedback loop which I think has led to the present rates of high prescribing," said Grant, observing that Canada now exhibits the second highest per capita usage of prescription opioids in the world.

Yeah, we're still #1 here in the U.S.

Some observations in light of these recommendations:

  1. A Canadian study suggests that veterinarians still receive 5X the number of hours of pain management training than physicians.  
  2. The American Medical Association (AMA) task force on opioid prescribing has been weak thus far in its recommendations.  
  3. The voluntary educational programs available today are valuable, but they're only capturing the good docs that have a sincere desire to do this right and make the time to learn best practices. 

If we're going to make real and rapid progress in the fight against prescription drug misuse and abuse, the AMA needs to get behind mandatory prescriber education.  Now.  

On Twitter @PRIUM1

Wednesday, September 16, 2015

CDC Opioid Guidelines: Poor Process for Public Participation

The CDC held a public comment webinar on a set of 12 proposed opioid prescribing guidelines.  I bet you'd like to know what those 12 recommendations are, right?  I wish I could tell you.  Here's how the webinar went:

The recommendations were not (and will not be) published.  Therefore, they cannot be circulated to anyone not able to join the webinar.  I tried to take good notes, but I didn't catch the recommendations with precision (and it's clear CDC is aiming for precision in its language).  Because I can't share them exactly as written, I'm not going to paraphrase from my notes.

But the webinar was recorded, right?  Yes, it was.  But "for archive purposes only."  The webinar recording will not be made available to the public.

No one could ask questions.  We were reminded several times that the webinar presenters couldn't answer questions.  We could only make comments.  To which there were, of course, no responses.

About 30 minutes in, there were technical difficulties and we had to start over.


If this is how the Centers for Disease Control and Prevention is going to handle the process of addressing the largest man-made epidemic in history, we're in trouble.  No dialogue, no exchange of ideas, no questions.  This webinar was about "checking a box" so CDC could say they solicited public comment - this was NOT about actually getting valuable feedback. 

A few observations I did make on the recommendations:

  • It's not clear whether these recommendations are useful for those patients already on chronic opioid therapy.  
  • There's no explicit discussion about informed consent or pain management agreements.  
  • CDC is suggesting "additional precautions" should be taken above 50 mg MED and dosages above 90 mg MED should be avoided.  What are those "additional precautions"?  They don't say.  
  • CDC appears to be suggesting naloxone should be considered for any long term opioid patient. This is going to be expensive.  
  • There's no discussion of weaning or tapering opioid (or polypharmacy) regimens.  
  • These guidelines are pointed in the right direction, but CDC's attempt at specificity has actually led to ambiguity.  Nearly every recommendation leaves several, critical open questions.  
  • This process is moving fast: CDC plans to submit these recommendations to HHS in early November and will be published in January.  
Here's my one comment:

Dear CDC: 
Make these recommendations publicly available, in written form, so doctors, patients, and other stakeholders can study them and offer you informed comment.  

On Twitter @PRIUM1