The Opioid Crisis: A Playbook Arrives

The Bloomberg School of Public Health at Johns Hopkins has published a paper entitled "The Prescription Opioid Epidemic: An Evidence Based Approach." Click here for a copy. Read it. Study it. Commit its recommendations to memory.  This is an important document in the fight against prescription drug misuse and abuse.

What makes it important is its comprehensiveness. The team at Hopkins attacks the issue at every step in the drug distribution value chain: prescribing guidelines, prescription drug monitoring databases (PDMPs), pharmacy benefit managers (PBMs) and pharmacies, overdose and addiction, and community based prevention strategies.

The document is the summation of work performed by seven sub-committees that discussed, debated, and deliberated the options for addressing opioid misuse and abuse.  The committees were made up of experts in the field and the passion, commitment, and resolve of these individuals is apparent in the resulting recommendations.

Perhaps most impressive, the paper appears to leave politics aside  (as any good public health institution should) and advocates for specific tactics that have long faced strident opposition from well-funded groups. Specifically, the paper calls for mandatory prescriber education and mandatory prescriber use of PDMPs... the American Medical Association has pushed back on the former and while they've recommended the latter, many state level medical associations have balked at mandatory PDMP use.

The paper should also be commended for suggesting innovative (though controversial) ideas, such as:

• Authorize third party payers to access PDMP data with proper protections
• Require oversight of pain treatment (through mandatory tracking of pain, mood, and functionality at each patient office visit)
• Empower licensing boards and law enforcement to investigate high risk prescribers
• Require that federal support for prescription drug misuse, abuse, and overdose interventions include outcome data

Work like this gives me hope.  

Michael 

On Twitter @PRIUM1

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?  

(Here's a hint: mandatory education would be a big help). 

Michael 

On Twitter @PRIUM1

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.  

Michael
On Twitter @PRIUM1