Concerns over opioid abuse are at a peak; increases in pain prescriptions and correlated rises in addiction reports and overdoses became a theme in the 2016 presidential campaign. The Centers for Disease Control and Prevention issued restrictive new guidelines for chronic pain prescribing in March 2016, and the President’s Commission on Combating Drug Addiction and the Opioid Crisis recently called for a new national policy. States have been ahead of the feds, with many instituting tough prescribing and dispensing restrictions; for example, effective Jan. 1, 2018, North Carolina’s STOP Act will restrict acute pain opioid prescription amounts to five days and postoperative opioid prescriptions to seven days.
In some cases, payers have reacted with their own restrictions. “Some insurance carriers are beginning to decline coverage for any opioids prescribed beyond the protocol recommended by the CDC,” says Nancy Irwin, Psy.D., primary therapist at Seasons Recovery Centers in Malibu, Calif.
Beyond The Law
It is, of course, important to keep up with the law, which can vary significantly from state to state. In some states, all prescriptions, including those for controlled substances, must be electronically written except in emergencies, but in other states, a paper prescription is required.
“We have to write out the scripts – can’t call it in at all,” says Barbara Bergin, M.D., an orthopedic surgeon with Texas Orthopedics, Sports and Rehabilitation Associates in Austin. “We can call in Tylenol #3 – which people who are habituated don’t like because it’s not strong enough for them. But anything stronger has to be written out on a prescription, which the patient has to hand deliver to the pharmacy.”
And in some states like Connecticut, it’s up to the provider to keep tabs on their patients’ opioid prescription history via prescription drug monitoring programs (PDMP), says Kate Fuss, a surgical physician assistant. Practice policy on opioids is, to a great extent, the practice’s call, and experts suggest that you nail that down to protect both providers and patients.
Some prescribers have worked out their own way of dealing with a patient whose PMDP record shows a recent opioid prescription. “In this case, typically I will prescribe them a third to a half of the original prescription I was going to write for [patients], as they do still need appropriate pain coverage postoperatively,” says Fuss. “Typically, there is not much push back.” When she gets “pillcounting” behavior – that is, when patients specifically comment on how many pills they have and how many they think they need – “the encounter becomes slightly more complex,” she says. If she is getting nowhere with the patient, she defers to a pain management specialist, either the patient’s own or one to whom she refers.
Make It A Policy
But one benefit of having a set practice policy that providers are expected to follow is “physicians can defer to the institution, which will have their back on their decisions,” says Celine Thum, M.D., director of emergency ultrasound and attending physician at a level I trauma center in New York City.
The drawback is that “sometimes the patient really does need the medication,” Thum says. Some flexibility can vitiate that side effect; just as some hospitals allow certain antibiotics to be prescribed only by its infectious disease specialists, so too a practice could allow only certain prescribers under certain conditions to write beyond the limits of the policy.
Some practices, for example, write narcotic contracts with patients where violations of such which will cause the provider to stop prescribing the drug, says Fuss. Others refer the patient to a pain management specialist if they feel uncomfortable prescribing opioids themselves.
Some try to provide alternative treatments. While opioids are an important part of the program at the Laser Spine Institute in Tampa, Fla., its chief medical director and cofounder, Michael Perry, M.D., says “we try to do everything we can to restrict the amount and dosage of narcotics by doing things others may not be doing” with a “multimodal” approach. That includes nonopioid pain treatments including “something called an IceMan that circulates cold water on their back” and drug cocktails such as Tylenol, Lyrica and Celebrex, “which studies show significantly reduces postoperative pain.” Perry says the practice keeps up with advance in pain management via peerreview journals and “if something is new and we think it might be an advantage, we assess it in every aspect,” he says.
Author: Roy Edroso, Part B News
Published Sep 11, 2017