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

Physicians and Painkillers: A Tale of Two Statistics

See if you can reconcile the following two sets of data points from a survey published by the Journal of the American Medical Association last week regarding physician perceptions of prescription drug abuse:

1) 90% of doctors report prescription drug abuse is a moderate to large problem in their communities and 85% think prescription drugs are overused in clinical practice.

2) 88% of those same doctors are confident in their skills related to prescribing painkillers and almost half of them are comfortable using the drugs for chronic, non-cancer pain.

And there's the rub.  Call this the old "there's a problem, but I'm not contributing to it" phenomenon.  Doctors who profess confidence and comfort prescribing prescription painkillers for chronic, non-cancer pain may be contributing the problem of misuse and abuse, albeit unwittingly.  The study doesn't offer any insights into dosage levels or medication classes or individual drugs, so one cannot draw conclusions.  And I'm certainly not suggesting that painkillers can't be used appropriately for time limited, function-focused management of chronic, non-cancer pain.  But the contrast between the data points struck me.  85% think the drugs are overused... 50% are confident using them with a group of patients for which there's little to no evidence of long term efficacy.  

And this is a commonly observed phenomenon.  Rewind the clock five, six, seven years and a material number of work comp payers (from carriers to TPAs to self-insured employers) were saying the same thing.  "There's a problem, but I'm not contributing to it." I personally heard it at least a dozen times in my first year here at PRIUM (which was five years ago... time flies).  I don't hear it much these days.  As an industry, we're beginning to make concerted, strategic effort to combat prescription drug misuse and abuse and we largely recognize that all payers have a role to play.  While there's still A LOT of work to be done, we've passed through the first step on the road to recovery: payers are not only admitting they have a problem, they're recognizing their past contributions to that problem.

The physician community appears to have the first half down - they're clear we have a problem.  I wonder if they recognize their past and current contributions to the problem.  I know many physicians do.  I hope more come to recognize the need to change patterns of practice in light of the largest man made epidemic in history.

Michael

On Twitter @PRIUM1