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

Necessary, but Insufficient: The AMA on Opioids

The American Medical Association has created a focused initiative to combat prescription drug misuse and abuse.  This is an encouraging step and I'm pleased to see this particular collection of healthcare associations, as invited by the AMA board of trustees, entering the fray with what appears to be real intent to change practice patterns and educate physicians.  But they have a long way to go if they really want to make a difference.

The first step of the Opioid Abuse Task Force is to encourage physicians to register for and use state-based Prescription Drug Monitoring Programs (PDMPs).  This is a classic political gambit for a highly political organization.  Are PDMPs critical to the fight against prescription drug misuse and abuse?  Absolutely.  Will a focus on PDMPs, by itself, create the kind of lasting change we need in the area of chronic pain management?  Not a chance.  It's as if the Task Force gathered in a room and asked themselves, "What's the least controversial thing we can do that still has a chance to make an impact?"  Given that lens, this is a good start.  But that's not the right lens through which to view the largest man-made epidemic in history and the most pervasive public health crisis of our time.

Granted, the AMA has described this only as a first step.  But there are tough political and economic decisions that lie ahead if the AMA really wants to stem the tide of prescription drug misuse and abuse.  For instance:

Will the AMA support mandatory physician education on safe prescribing of opioids (and other potentially addictive medications)?  Will they support mandatory education on best practices in chronic pain management?

Will the AMA take a position against physician dispensing?  Among the most well-financed and well-organized opponents of legislation calling for bans and/or limitations on physician dispensing have been state-based medical associations.  The AMA has an opportunity to change the debate on this important topic.  Will they?

Will the AMA support efforts at the state level, across the payer spectrum, to deploy evidence based medical guidelines and create utilization review programs so that payers have the tools they need to ensure the medical necessity of prescription medications?

Will the AMA take a position on urine drug monitoring for chronic pain patients?  While a critical tool for ensuring patient compliance and preventing diversion, testing is often abused by physicians as a practice revenue generator.  Will the AMA work with the payer community to stop this and ensure the monitoring is used for medically necessary and clinically relevant purposes?  

The fight against prescription drug misuse and abuse is a tough one.  The AMA is going to have to come to the table with more than PDMPs.  I hope the next few steps in the Task Force plan show the political courage necessary to create lasting change.

Michael
On Twitter @PRIUM1