Arizona Physician

Arizona Physician

Opioid Prescribing and Regulation: What Physicians Think

By Sharla Hooper

Drug overdose is now the leading cause of accidental death in the U.S., with 52,404 lethal drug overdoses in 2015. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015. The opioid epidemic is a serious problem in Arizona, and our medical community and policymakers have been working to address it in various ways. We asked physicians to consider these aspects of the opioid crisis in our most recent survey, and we thank those who shared their views and experiences.

In 2015, more than 600 Arizonans died from opioid abuse. One of our medical student respondents saw the effects first-hand: “…it seemed a majority of cases I saw during my medical examiner rotation were deaths from opioid overdose.”

Pain as the 5th Vital Sign…Patients as Customers

Current policy at the Centers for Medicare and Medicaid Services (CMS) provides hospitals with incentive payments based on patient satisfaction surveys related to how well they felt their pain was controlled. While 26.7% of respondents agreed with the policy but also felt it contributed to overprescribing of pain medication, 59% disagreed with the policy altogether.

Several respondents felt strongly that this policy is a contributing factor to overprescribing opioids. “I believe adding “pain” as a vital sign and patient satisfaction scores has turned medicine from the practice of treating patients to the business of keeping customers happy which in the majority of cases is heavily linked to patient’s perception of how their pain was managed.  This is ultimately detrimental to both the patient’s well-being and the physician’s ability to treat them objectively without the influence of how they will be rated after each encounter.”

And one respondent saw a correlation between the impetus of opioid overprescribing and the intervention: “The powers that be who mandated treatment of pain as the fifth vital sign and admonished doctors for their heartless behavior are the same geniuses who now feel that they need to regulate physician-patient relationship again in pain management.” 

Regulatory Intervention

In considering regulatory interventions being implemented, physician respondents were wary. Based on the respondent comments, this is related to retaining physician autonomy in making the determination for themselves, rather than at the behest of government regulation or statute. As one respondent stated, “I’m leery of any “requirements” made by politicians and non-physician led healthcare companies. I do not think I like the idea of limiting any physician’s prescribing abilities simply because of what type of physician they are. Physician autonomy should be respected and the doctor-patient relationship held to the highest ethical standards while maintaining this autonomy.”

Asked about the executive order that instructed AHCCCS (Arizona’s Medicaid program) to establish new guidelines limiting initial opioid prescriptions to seven days for all employees on the state’s insurance plan and all AHCCCS patients, the responses indicated a conflict. 31.1 % agreed with the guidelines but had concerns; 41.7% did not agree with the guidelines and felt the decision has a detrimental impact on the doctor-patient relationship. One respondent stated, “Most physicians who prescribe opioids do so in an ethical and appropriate manner and don’t need politicians second-guessing their prescribing practices.”

Others saw this as an action punishing many for the actions of a few: “…providers who are identified as high prescribes should be monitored more closely rather than instituting more regulations on everyone. We are already overburdened with extra work and monitoring.”

The Role of Education

Given general misgivings about medical education mandates by government, it was somewhat surprising to see 63.4% of respondents agreed that opioid-related continuing medical education (CME) should be required, either for all licensed physicians or for all physicians with DEA licenses.

Several respondents identified a dearth in drug addiction education for physicians. “I worked for a drug rehabilitation detoxing patients prior to medical school. Once I went to medical school and as a resident, I quickly learned how little physicians know about drug use and abuse. There needs to be more mandated education and it needs to start at the medical school level.”

An educator stated, “I review opioid prescribers for the authorities, and am only given 1 1/2 hours to teach opioid prescribing to U of A med students in their four-year program. More intense education is needed.”

The current request of Arizona Governor Ducey is that the Arizona Medical Board establish a required one hour of CME for the biennial physician licensing term, which requires a total of 40 hours of CME. One respondent felt strongly that this was inadequate: “I also hold an active California license and have been required to complete a mandatory 15 hours of CME on pain management focusing on opioids in order to keep my license even though I do not have a DEA number and do not prescribe opioids. One hour of CME is inadequate to bring physicians to a level of knowledge where they should continue…to prescribe opioids. They need 30 hours. The epidemic of opioid deaths in Arizona is real and it is caused by physicians’ irresponsible prescription of opioids.”

Mandated Reporting in CSPMP

Asked about mandated reporting of opioid prescribing in the Arizona Controlled Substance Prescription Monitoring Program (CSPMP), 45.2% of respondents thought it should be mandatory, but in our comments, there were numerous statements indicating that pharmacies are the key point of tracking opioid prescriptions; that is where they are filled: “I believe a more efficient place for tracking prescriptions is with the pharmacies rather than asking the providers to register each opioid prescription.”

And as one respondent pointed out, more documentation regulation requirements are not welcome: “Prescriptions should be registered by pharmacists and dispensing bodies, not by physicians or their practices. Too much regulation documentation already trickles up to be dumped on increasingly data entry doctors.”

One physician pointed out that effective communication with pharmacists is already making a difference: “Assistance from our pharmacy colleagues in notifying us of patients receiving opioids from multiple sources is the most helpful support I have experienced.”

Deficiencies in the CSPMP technology must be addressed to facilitate its use. As one respondent stated, “…it is critically important for any PMP to focus on integration with physicians’ computer systems by providing a web interface using modern, standardized technology rather than individual system integrations.”

Treating Chronic Pain

A number of pain specialists shared their concerns as well, pointing out that regulations are swinging the pendulum too far the other way: “Pain patients are treated like criminals. Those with chronic pain have to worry every month about availability of needed meds. We’re throwing out the baby with the bath water.”

There was clear concern for patients struggling with chronic pain and how regulations could affect their care: “Pain is a complex syndrome. There is a clear difference between acute vs. chronic. Making limitations across the board limits clinical syndrome needs.”

Several pointed out the importance of distinguishing between short-term acute pain management and chronic, long-term pain management. “Most…cases of overdose are related to prescriptions written for an acute injury like surgery and not from patients who are using opioids to control their chronic pain.”

“It’s important not to make it impossible for patients with chronic pain to access a therapy that is effective for an individual. There should be stricter guidelines for short-term prescriptions and in certain situations like for control of post-op pain.”

However, as one physician stated, “Unfortunately, those two issues are often treated the same by our politicians. For example, A.R.S. 36-2606 only allows ten days for recovery from surgery, which is often an inadequate period of time.”

Inadequacies of Health Care and Support Systems

Respondents also had concerns about the lack of prevention systems and addiction resources in the existing health care system. One respondent stated, “A significant % of patients’ first exposure to opioids is for post-op pain control. Enhanced Recovery programs and multimodality pain control should be required in all hospitals, in the same way in which enhanced recovery was mandated in the UK by the NHS several years ago. The USA is far behind on this issue.”

Asked about the statistic of increased overdoses by children in homes with opioid prescriptions, 76.9% felt that physicians should take extra caution in prescribing opioids to mothers with young children in the home by providing additional literature and counseling to the mother. One respondent was deeply concerned by the “Demonizing [of] pregnant women” and that removing children “from homes, placed in foster care, is incredibly detrimental to children, families, and society. Opioid abuse should be prevented and treated, not criminalized.”

Another respondent shared that in their experience, problems encountered in patient care include the fact that the use of alternative therapies such as pain creams have shown results, have no diversion issues and less chance of abuse, but are not paid by insurance plans. Additionally, “The patients need Psych Counselling at the time of prescriptions,” not paid by Insurance Plans at the PCP or Pain Clinics.”

One respondent offered a profoundly simple observation and a reminder that a simple DEA designation paired with Suboxone training can make all the difference: “I am working in a Recovery Center on Indian School Ave. and see the desperate need for Addiction services.  My “X” DEA designation allows Suboxone Rxing. It is a life saver.”

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