Looking for Balance in Prescribing Opioids
By Larry Beresford
More than 42,000 Americans died of opioid overdoses in 2016. Although the public health crisis of nonmedical opioid use is complex and multifactorial, including consideration of patients who were prescribed opioid analgesics for pain, the illicit diversion of prescribed analgesics, and the use of street drugs, the consequences have been devastating for society. And reactions to the crisis—by regulators, legislators, the news media, health payers, and others—inevitably will impact providers of hospice and palliative care and their patients.
A March 28 report from the Centers for Disease Control and Prevention (CDC) indicated that overdose deaths in 2016 were up 28% over the year before, with an unprecedented surge attributed to illegally manufactured fentanyl and other synthetic opioids. According to the CDC, the increased prescribing of opioids to relieve pain, which started in the late 1990s, led to widespread nonmedical use of both prescription and nonprescription drugs, which were found to be more addictive than previously believed.
Declaring a public health emergency in October of 2017, the Department of Health and Human Services issued a five-point federal strategy, including better practices for pain management, to address it. The economic burden of the opioid epidemic has been estimated at $78.5 billion per year.1 At the same time, Judith Paice2 has documented a 42% rate of inadequate analgesia for patients with cancer, as perceived by the patients, two-thirds of whom reported at least one barrier to pain management.
Although our purpose remains clear—to relieve the pain and suffering of patients with serious, advanced, or life-threatening illnesses—hospice and palliative care prescribers need to be aware of these larger currents in society and consider harm reduction strategies in how they prescribe opioid analgesics. The goal is to balance harm prevention with the imperative for relieving suffering. But the national climate clearly has changed, with a resulting pendulum swing toward more restrictions on prescribing.
“How does our specialty deal with the facts of this opioid overdose epidemic?” said AAHPM Chief Medical Officer Joe Rotella, MD MBA HMDC FAAHPM. “How do we keep two truths in mind at the same time? Many people suffer from pain, and opioids, in many cases, are their best option. We are able to use them safely for a lot of our patients. But we also want the public to be safe, minimizing nonmedical use and diversion. Folks in our field are trying to help those trying to solve the opioid crisis, not to do it in a heavy-handed way. We need to have balance and we want to be part of the solution—without abandoning our patients and their needs.”
“First of all, we need to acknowledge that this is a tremendous problem and there are lots of people using opioid analgesics inappropriately,” said Amy Davis, DO MS FACP FAAHPM, a palliative medicine practitioner in Bryn Mawr, PA. “There’s also a growing number of people who have serious illness and an active substance use disorder.” Others may have a history of use, which impacts their pain treatment today, or else the family caregiver or another close family connection may be the source of the concern. “Then there’s another group we rarely talk about, which is staff who have substance use disorders. All of this has impacted hospice and palliative care and how we practice,” Davis said.
Techniques of Opioid Harm Mitigation
AAHPM reported on these larger currents in a cover story in this publication in 2015,3 detailing restrictions, stigmatization, and a variety of negative impacts on hospice, palliative care, and pain care practitioners. At that time, AAHPM members voiced concerns that state and federal laws to reduce opioid prescribing were profoundly affecting their clinical practices and threatening to undermine physician-patient relationships. The article outlined basic techniques of risk reduction imported from the pain and addiction medicine fields. These include opioid use risk assessments, patient prescribing agreements, urine drug testing, state prescription drug monitoring programs (PDMPs), consultations with addiction specialists, and lock boxes for medications in homes that are not secure.
In the meantime, overdose death rates have only mounted. Reactions across sectors have intensified, and hospice and palliative care prescribers are seeing increased restrictions on their prescribing at the federal, state, and local levels. Even when hospice and palliative care patients explicitly are excluded from new restrictions on prescribing, they still can get caught in the crossfire.
“Everybody’s suspicion is up, and doctors are becoming fearful,” said Mary Lynn McPherson, PharmD MA, executive director of advanced post-graduate education in palliative care at the University of Maryland. “It really makes everybody think twice about everything they do. But it’s a good thing to be more discriminating about the use of these drugs. Ask yourself: Is this pain opioid responsive? Is there any other stone left unturned in seeking treatment alternatives? And always revisit the plan of care: Is this drug meeting the patient’s goals? Which we should be doing anyway,” she added.
“There can be a real tendency to throw the baby out with the bathwater,” said Ronald Crossno, MD FAAFP FAAHPM, who is based in Rockdale, TX, and serves as chief medical officer for Kindred at Home. Although some of the fixes being proposed are reasonable in a setting of chronic pain management, many are not reasonable for patients who are seriously ill, who can’t get to a pain clinic for monthly follow-up visits, or whose life expectancy is measured in months.
“Hospice doctors are high-volume prescribers—and rightly so—but that can label them as pill pushers who need to be closely watched by regulators,” Crossno said. “That’s particularly problematic in hospice, where so many doctors work part time and have to be concerned about the impact on the rest of their practice.” It is essential for hospices and their medical directors to know the rules in their state, which can vary widely. “It’s definitely put doctors back on their heels, feeling defensive. But maybe it’s good for us to be proactive and ready to explain our prescribing practices,” he said. “Ten years ago, I would have thought it ludicrous to give a urine test to a palliative care patient, but now it’s almost becoming a standard of care.”
Daniel Fischberg, MD PhD FAAHPM, medical director for the Pain and Palliative Care Department at The Queen’s Medical Center, Honolulu, HI, agrees that a palliative care program using none of the recognized risk strategies is somewhat outside of mainstream practice today. But the jury is still out on whether the time and effort put into risk assessments and urine screenings for every patient in palliative care actually improves patient safety in quantifiable ways, he said.
“I’m sure it helps for some, and even if the data are limited, it seems like common sense. Our service is both a pain and a palliative care service, so I see it both ways. And as palliative care moves upstream to serve patients earlier in their disease progression, which we all want, it blurs the boundaries. We’re seeing more people who also are receiving curative therapies, so programs are challenged to figure out their mission and the population they want to serve.”
Fischberg encourages palliative care programs to arrange access to a consulting psychologist, psychiatrist, and/or addiction specialist. Programs can counsel their patients on how to keep medications safe, locked up, and away from children and others—along with educating them about issues of diversion, addiction, and prevention.
Other Approaches to Pain Management
Not all pain is the same, and some pain will respond better to ibuprofen or a combination of NSAIDs and acetaminophen than opioids, Crossno said. Neuropathic pain responds better to seizure medications or antidepressants. Complementary and alternative medicine (CAM) also is worth considering, although some CAM therapies don’t have much data to support them yet, he said. “The other problem with CAM is that doctors don’t have much experience using it. You may need to send the patient to a different practitioner for each therapy, and insurance generally doesn’t cover it.”
Psychosocial and complementary methods of pain management may be important components of an opioid-sparing strategy. The Society of Behavioral Medicine recently issued a position statement calling for more psychosocial care—and coverage—for patients with persistent pain.4 Other approaches range from guided imagery and massage to music therapy, acupuncture, and even cannabinoid-based therapies.
According to Davis, behavioral medicine interventions and the role of chaplain and social worker in addressing spiritual pain haven’t been emphasized enough by hospices. “There are certain other interventions that easily can be done in outpatient and inpatient settings without a lot of additional cost. Then there are beneficial things that need financial support, for example acupuncture, which is backed by solid evidence,” she said. Cognitive behavioral therapy in a limited number of sessions can help identify what is preventing the person from doing as much as they could be doing to self-manage their pain.
“When I talk to professional groups, I tell them: Start with what you know. This (analgesia) is medicine—and it’s no different from any other medicine,” Davis said. “You have a person in front of you with a pain complaint. You do a thorough history and physical, looking at their risks for opioids—or any treatment. If the risks are too high relative to the benefit, then you look for alternatives or ways to reduce the risk. And if you need to bring in an addiction expert, just as you would with a cardiologist, then you do that. When it comes to the risk for diversion, I’m not a cop, and you don’t need to be a cop. You just need to be vigilant and to use a medical model of risk-benefit analysis.”
Terri Maxwell, PhD APRN, vice president of clinical education at the Philadelphia-based hospice pharmacy benefit management firm Enclara Pharmacia, believes the palliative care field has been too slow to respond to the opioid crisis. “We need to educate ourselves on how to be better stewards of these medications. I am a huge advocate for making sure we have exemptions for hospice and palliative care. But even with the exemptions, the barriers designed to decrease use of opioids in society have unintended consequences,” she said.
“I’m also an advocate for saying we can’t be naïve about the issues; we need to be sure that we’re not putting more opioids into the home than necessary and that we’re assisting with proper disposal of unneeded medications. Are we assessing for opioid use disorder in our patient population and then taking steps accordingly based on identified risk to put safeguards in place?”
Enclara teaches its hospice clients how to evaluate for risk and to figure out their role in risk reduction. “Hospices are going to have to develop policies and procedures to play their part in decreasing the drug supply, using pill counts, etc. It’s about thinking these issues through,” Maxwell said. “How do you get your staff nurses to take the risks seriously, to consistently assess the risk for potential abuse, and to recognize when there might be a problem?”
A Clinic-Wide Approach to Managing Risk
Kathleen Broglio, DNP APRN, a nurse practitioner in the palliative care clinic at Dartmouth Hitchcock Medical Center, has participated in the development and implementation of opioid management guidelines for the clinic, based on principles of universal precautions. “Potentially, anyone could be at risk, just as everyone has potential for infection. Clinicians are not good at predicting who is at higher risk just based on how they look,” she said. “I came here from the pain management field. We have known about a potential problem with opioid therapy since 2003,” even though only a small percentage of those who are prescribed opioids for pain relief go on to use them not as intended.
At Dartmouth, since-retired palliative care physician Ellen Bassett, MD, noted that New Hampshire had the country’s third-highest rate of overdose deaths and started looking at palliative care patients, recognizing that they weren’t all that different from the population at large. “There was a lot of discussion about whether universal precautions would make patients feel uncomfortable, but everybody agreed that we needed to implement opioid management measures and develop prescribing guidelines for how to operationalize this in a busy palliative care clinic. We wanted to standardize it,” Broglio explained.
“But everyone working in the clinic has to be on board with implementing the guidelines. We meet to discuss tough patients—and anyone assessed at high risk. The primary clinician gets called if questions come up after hours that can’t be answered by the clinician on call,” she said. It means not only getting buy-in from the palliative care team, but from referral sources as well. “When a referral is made for pain management to palliative care, we make it clear that we are now managing the patient’s pain. That’s really important, as you don’t want patients getting mixed messages secondary to different prescribing patterns.”
Everyone seen in the clinic and prescribed opioids now undergoes opioid risk screening, PDMP checks on each visit, completion of a treatment agreement, and random urine drug screens. Patients are prescribed naloxone reversal kits if they are on higher doses of opioids or assessed to be at higher risk. “If a patient is stratified as being high risk, we see them often, and our social worker is engaged in every visit. When we see potential use not as prescribed or intended, we can take other steps, such as seeing the patient more frequently, doing weekly prescriptions, prescribing opioids with less street value, or exploring treatment alternatives,” said Broglio. The clinic also offers opioid agonist treatment using buprenorphine to treat patients with serious illness and comorbid substance use disorders.
“My overarching message is that all of us in palliative care should consider screening all patients being prescribed opioids for risk of opioid use disorder. And it should be normalized, not stigmatized—the same way we do with informed consent for anything else in medicine, such as patients getting informed of the risks and benefits of surgery,” she said. “We have some patients who are afraid to take opioids because of what they read in the media. We’ve been able to reassure them that because of our guidelines, we’ll be watching them closely. And so we’re able to normalize it.”
The goal is not to be punitive or to deny treatment to anyone, Broglio added. “Substance use disorder is a disease, and we have an ethical obligation to care for these patients in need. But that means finding the balancing point where we can practice harm reduction and find ways to prevent and mitigate the negative consequences while still relieving our patients’ pain.”
To learn more, visit aahpm.org/opioids.
- Florence CS, Zhou C, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care. 2016;54(10):901–906.
- Paice JA. Cancer pain management and the opioid crisis in America: how to preserve hard-earned gains in improving the quality of cancer pain management [published online ahead of print March 2, 2018]. Cancer. doi: 10.1002/cncr.31303.
- Martinsons J. Seeking balance in opioid prescribing. American Academy of Hospice and Palliative Medicine Quarterly Newsletter. 2015 Spring;13:12–15.
- Janke EA, Cheatle M, Keefe FJ, Dhingra L; Society of Behavioral Medicine Health Policy Committee. Society of Behavioral Medicine (SBM) position statement: improving access to psychosocial care for individuals with persistent pain: supporting the National Pain Strategy’s call for interdisciplinary pain care. Trans Behav Med. 2018;8(2):305–308.
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