Seeking Balance in Opioid Prescribing
In the complex and controversial world of opioid prescribing, the proverbial swinging pendulum is neither showing signs of slowing nor settling on a workable center between patients’ access to pain medications and public safety. For people on the ground, including hospice and palliative medicine physicians and their “sickest of the sick” patients, the pendulum can cut precariously close, threatening to undercut everyday clinical practice and undermine physician-patient relationships.
Indeed several hospice and palliative medicine physicians who spoke to AAHPM Quarterly say that recently enacted state and federal laws to curb opioid prescribing, and particularly the US Drug Enforcement Agency’s move last year to reclassify hydrocodone as a Schedule II controlled substance, are profoundly affecting clinical practice and their interactions with patients and pharmacies.
“Absolutely the climate has changed” in the last few years, says Ronald J. Crossno, MD FAAFP FAAHPM, vice president of medical affairs and chief medical officer of Kindred at Home in Temple, TX, and a past president of AAHPM. “We’re routinely getting referrals of chronic pain patients to the hospice setting even when they are not really hospice eligible. With private practitioners realizing that they don’t want to fool with the opioid restrictions, many try to hand their patients to anybody they can.”
A case in point is Shannon Medical Center in San Angelo, TX, where the number of new patient referrals jumped from an average of 5 to 50 per week after hydrocodone was reclassified from a Schedule III to a Schedule II drug. Vayden Stanley, MD, a pain management physician at Shannon, also notes that when regulators make examples of one or two hospital physicians by revoking their licenses to prescribe opioids, “suddenly, out of nowhere, I’ll get 10 or 15 referrals to the pain clinic. I’m burning up!” he says. ”When physician clinics or groups don’t allow their physicians to prescribe any controlled substances, it really puts the onus on pain clinics in the area. It’s becoming a burden for us.”
Moreover, state laws that require primary care physicians to seek pain management consultations for opioid prescriptions over certain amounts are putting undue strain on pain management physicians, says Dr. Crossno. “There are not enough pain management experts in the country to handle all the consults,” he says, explaining that the situation is particularly complicated for hospice and palliative medicine physicians who may be exempt from the laws because of their training. “That level of expertise applies only to the hospice and palliative care setting, in which patients have serious or life-threatening conditions. Chronic, ambulatory pain patients who traditionally were managed by primary care physicians are now looking for anyone who can prescribe and manage their pain.”
Meanwhile, patients can wait for days for medications while primary care physicians seek a consulting specialist, even when only minor adjustments to medications may be needed, says Chad D. Kollas, MD FACP FCLM FAAHPM, medical director, Palliative and Supportive Care, UF Health Cancer Center–Orlando Health in Orlando, FL. “If I’m not immediately consulted, I know patients are going to have pain for a day or two,” he says. “We spend a large part of our day talking with pharmacies, trying to make them understand that this is why the patient is taking the medication. Some pharmacies not only ask for diagnoses, but for ICD-9 codes as well.”
Changes in Prescribing
Prescribing is changing in other ways as well. Joe Shega, MD, regional medical director, VITAS Healthcare, who resides in Gotha, FL, says that when he travels in his state, Georgia, or Alabama, it is not uncommon to see signs in the offices of primary care physicians that read, “We will not prescribe opioids for pain.” He notes that his own opioid prescribing has changed dramatically over the last couple of years and now routinely includes a risk assessment of patients for possible diversion and addiction.
In Florida, where new laws aimed at reducing opioid prescribing distinguish between patients with cancer-related and noncancer-related pain, Dr. Kollas notes that for cancer patients, he’s “become more specific in my prescription writing so that the pharmacies understand exactly what medication the patient is getting.” For example, he says, “for breakthrough cancer-related pain, I may write in parenthesis on the prescription, ‘Chest wall pain from postmastectomy pain due to breast cancer,’ which is a lot to put in a written prescription.”
For patients with noncancer-related pain, the Florida law mandates prescribing agreements that include urine drug screens and physician consultations on addiction and diversion. “The law keeps us busy,” says Dr. Kollas, who, as a board-certified physician in hospice and palliative medicine, opted to use prescribing agreements with patients, even though hospice physicians are exempt under the law. He concedes that he initially took umbrage with the extra work, but has since grown to see the value of the prescribing agreements. He adds that opioid-related deaths continue to drop in the state once infamous for its “pill mills,” although heroin-related deaths increased 89% in Florida in 2012, the first year new laws went into effect.
E-prescribing continues to take hold among hospices—no surprise considering that all states but one, Missouri, have some form of PDMP. Dr. Shega, formerly a geriatric medicine specialist with the University of Chicago’s Medical Center in Chicago, says that physicians at VITAS have embraced electronic prescriptions for Schedule II drugs since being piloted and rolled out a couple of months ago.
Working with Pharmacies
Not all physicians are changing their prescribing habits, however. Phillip A. Peterson, MD CMD, of Bluefield Family Medicine, Bluefield, VA, says that his opioid prescribing has remained the same, but that his dealing with pharmacies has changed. Gone are the days of nurses filling prescription orders, he says; today he calls in orders himself and later signs hard-copy receipts so prescriptions can be filled.
“The complexities and barriers to getting prescriptions filled have increased, especially with hydrocodone,” says Dr. Peterson, who heads AAHPM’s Rural Special Interest Group. “It’s added more work for my nurse and me, compared with 2 or 3 years ago, when these rescheduling changes took place.” Moreover, patients who have been on prescribed opioids for years now must come to his office every month for a new prescription—a real inconvenience for those who need to travel as much as 2 hours to his facility in Appalachia.
Nationwide, laws to reduce opioid prescribing have had a “real chilling effect,” says Dr. Kollas, the Academy’s delegate to the American Medical Association and chair of its Pain and Palliative Medicine Specialty Section Council. Pharmacies are increasingly reluctant to “do business in opioid medications” and are taking either precautionary or mandatory steps to contact physicians directly to confirm their diagnosis or treatment.
He further notes that patients are having difficulty filling their prescriptions. On the day Dr. Kollas spoke to AAHPM Quarterly, four of six of his patients with cancer-related pain were having trouble filling their opioid prescriptions—a common end-of-the-month occurrence among pharmacies facing restrictions on the amount of medications they can dispense, he explains. Not only do these shortages leave patients in a lurch, but pharmacies that still have available medications at month’s end fear being robbed by illicit drug users and traffickers.
Education Is Needed
All of this is raising concern among hospice and palliative care patients and their families, who are asking more questions about addiction and diversion than ever before. According to Dr. Shega, many families report anxiety over bringing opioids into the home, particularly patients living in intergenerational homes with teenagers and children.
Dr. Kollas believes there is less trust in the patient-physician relationship than there was before and heightened scrutiny of opioid prescribing is stigmatizing patients with legitimate pain. “Patients ‘get it’ because they have trouble other places. I almost never see a new sickle cell patient who isn’t aware that there is difficulty getting pain medications. They tell me many physicians mistrust them when they are seeking renewals for controlled pain medications and treat them ‘like drug addicts.’”
The physicians who spoke to AAHPM Quarterly agree that, despite the amount of direct contact that physicians may have with their patients, it is vital that they educate them about diversion and addiction, prevention measures such as lockboxes, and the proper and lawful disposal of medications in their state. They also need to update them on changing protocols. In Florida, for example, patients should be made aware that they can now drop off unneeded medications at pharmacies on an ongoing basis rather than at periodic state-sponsored events.
These physicians also stress that patients’ knowledge of diversion varies widely, from those who naïvely find it is acceptable to exchange medications with others, to what one physician describes as the “small but very vocal minority of self-educated activists,” to patients who readily comply with regulations, to those who wrongly blame doctors for stricter requirements on opioid medication.
It’s why “physician prescribers need to be experts” on evidence-based opioid prescribing, Dr. Crossno says. “The thing that saddens me is how little education has been provided in the past regarding the nuts and bolts of prescribing opioids.” That must change, says the AAHPM representative to the Collaborative for REMS Educations (CO*RE), the largest provider of Opioid REMS education.
“It’s important that the CO*RE curriculum is taught to a broader group of physicians, including those who work in pain and palliative care” Dr. Crossno stresses. “The curriculum must take into account the chronic ambulatory pain patient, palliative care pain patient, and dying hospice pain patient.” He notes that a free CO*RE preconference session was featured at the 2015 AAHPM & HPNA Annual Assembly on February 25.
Other Treatment Options
Meanwhile, hospice and palliative medicine physicians are also turning to alternative treatment options for pain, including physical therapy, occupational therapy, guided imagery, biofeedback to manage anxiety and pain, acupuncture, and heat and cold therapies.
Physicians are using other classes and combinations of medications, as well as other treatments for pain, says Dr. Kollas, but are doing so in a patient-specific manner. He stresses the importance of working with other members of the interdisciplinary team, including nurses, social workers, and pharmacists. “You want to optimize [patients’] functional levels in a way that causes the fewest side effects or problems with their medication,” he says. “Using all of these tools helps obtain that goal.”
A Host of Concerns
There is no shortage of concerns and opinions about opioid prescribing:
Phillip A. Peterson, MD CMD
“There continues to be some talk that, in the future, a face-to-face relationship may be required for a physician to prescribe opiates to a hospice patient. That is very frightening to me because, if that were to occur, many of my patients either would be seriously delayed in getting their medications or may not even be able to get them at all.” He notes that video chat is not always feasible in his rugged Appalachian area either due to a lack of available cell service or because many of his hospice patients lack access to computers and smartphones.
On the political front, Dr. Peterson says: “To help prevent unnecessary, even harmful laws and regulations, it is important for policymakers to subject themselves to the same standards to which they hold us in medicine. [They] need to use evidence-based guidelines before creating new policies that may be ineffective or make it difficult, if not impossible, for patients to get the medications they need.”
Joe Shega, MD
“Additional restrictions and encumbrances due to increased regulatory requirements will continue to impact supplies of opioids and their availability. The most recent data suggest that greater efforts have, in fact, decreased prescription opioid abuse, which coincidentally was associated with a reported increase in heroin-related deaths,” Dr. Shega says. “I also think that in the longer term, technology might be developed where a computer chip is embedded into formulations that can be monitored and tracked, but that’s likely years away.
“Another issue is that the use of tramadol, which is now a Schedule IV medication, is becoming more popular among clinicians. People feel there are fewer regulatory concerns with it, but that also might lead to tramadol getting reclassified, as hydrocodone was.”
Vayden Stanley, MD
Besides physicians needing to be well educated on opioid-prescribing regulations, Dr. Stanley recommends that they get to know their regulators on a first-name, informal basis. As medical director of a local methadone clinic, he says that by getting to know the regulators in his area, which is only 100 miles from the Mexican border, he better understands the problems they face with drug smuggling and diversion, which has become more acute with the recent oil boon.
Ronald J. Crossno, MD FAAFP FAAHPM
“We shouldn’t be afraid of these drugs [opioids]; we should respect them. We need to do whatever is necessary to get somebody’s pain under control in the hospice setting. In other settings, we should do whatever is necessary to manage pain and make patients as functional as possible.”
In coming years, “we are going to continue to see increased regulatory scrutiny, mostly at the state level,” Dr. Crossno says, pointing to possible delays in prescribing under state-mandated prescription drug monitoring programs. “Over the next year or two, it may be prudent for us to work for increased restrictions, but to make sure there are exceptions when they make sense. That’s been the advocacy effort of the Academy and our state policies working group.”
Chad D. Kollas, MD FACP FCLM FAAHPM
Dr. Kollas compares the government’s efforts to reduce opioid prescribing to trying to lower automobile deaths by limiting the number of cars on the road. Think back, he says. “When the government was confronted with automobile safety issues, we learned to make safer cars, better educate drivers, and make the roads safer. We need to do the same in the world of controlled pain medicine by doing a better job of educating our patients about the risk of pain medicine and communicating information to pharmacies through prescription monitoring programs in all states,” he states. “Saying that we need fewer medicines is not a solution.”