Skip to main content
AAHPM Logo
Login
  • Join/Renew
  • Donate
  • Blog
  • Contact
Menu Search Account
  • Membership
    • Join/Renew
      • Member Benefits
    • Diversity, Equity & Inclusion
      • DEI Resources
    • Member Center
    • Getting Involved
    • Communities
      • SIG Instructions
      • Join a SIG
      • Member Councils
    • Mentoring
    • FAAHPM
      • Current Fellows
  • Education & Practice
    • Writing Instructional Objectives
    • Meetings
      • Leadership Forum: Ascend
      • Annual Assembly
        • Back to Meetings
        • Assembly Home
        • About the Assembly
          • Why Attend
        • Registration
        • Special Events
        • Educational Sessions
          • Keynotes
          • Wednesday
          • Thursday
          • Friday
          • Saturday
        • Plan Your Experience
        • CE and MOC
        • Summer Call for Abstracts
        • Fall Call for Abstracts
        • Assembly FAQs
        • Business Meeting
        • Health and Safety
        • Exhibits & Advertising
      • State of the Science
      • State of the Science
        • Back to Meetings
        • State of the Science Home
        • Plan Your Experience
        • Schedule and Pricing
        • SOTS FAQ
        • Virtual State of the Science
      • Intensive Review Course
        • Back to Meetings
        • Home
        • Schedule
        • Plan Your Trip
      • Advanced Course in Pain
        • Back to Meetings
        • Home
        • Plan Your Trip
      • Intensive Board Review Course 2018 Recordings
      • IBRC18 - Additional Management Strategies for Cancer Related Symptoms
      • IBRC18 - Approaches to Care, including Hospice/Medicare
      • IBRC18 - Assessment and Care of the Dying Patient
      • IBRC18 - Communication and Teamwork
      • IBRC18 - Depression/Anxiety & Other Mood Disorders
      • IBRC18 - Ethical and Legal Decision Making
      • IBRC18 - Grief and Bereavement and Spiritual Care
      • IBRC18 - High Yield Pediatrics for the Boards
      • IBRC18 - Non-Pain Symptom Management – GI
      • IBRC18 - Non-Pain Symptom Management – Respiratory
      • IBRC18 - Non-Pain Symptom Management: Pot-Pourri
      • IBRC18 - Pain Management Overview
      • IBRC18 - Palliative Sedation/Physician-Assisted Dying/Discontinuation of Technological Support
      • IBRC18 - Practice Test Question Review Q&A (1)
      • IBRC18 - Practice Test Question Review Q&A (2)
      • IBRC18 - Practice Test Question Review Q&A (3)
      • IBRC18 - Prognostication
      • IBRC18 - Special Topics in Pain Management
      • IBRC18 - Symptom Potpourri
      • IBRC18 - Taking the Test Like a Pro
      • IBRC18 - Urgent Medical Conditions
    • Publications
      • JPSM
        • Members JPSM
      • PC-FACS
        • Members - PC-FACS
      • Quarterly
        • Members Quarterly Full Access
        • Spring 18 Clinical Pearls
        • Spring 18 Diversity & Inclusion
        • Spring 18 Feature
        • Spring 18 HMDCB Update
        • Spring 18 Pathways to Palliative Care
        • Spring 18 Presidents Message
        • Spring 18 Quarterly Progress Report
        • Spring 18 AAHPM News
        • Spring 18 Art of Caring
        • Summer 18 AAHPM News
        • Summer 18 Advocacy Update
        • Summer 18 Annual Assembly
        • Summer 18 Art of Caring
        • Summer 18 Clinical Pearls
        • Summer 18 Ethics
        • Summer 18 Feature
        • Summer 18 HMDCB Update
        • Summer 18 Pathways to Palliative Care
        • Summer 18 President's Message
        • Summer 18 Quarterly Progress Report
        • Fall 18 AAHPM News
        • Fall 18 Annual Assembly
        • Fall 18 Art of Caring
        • Fall 18 Clinical Pearls
        • Fall 18 Diversity & Inclusion
        • Fall 18 Feature
        • Fall 18 HMDCB Update
        • Fall 18 Pathways to Palliative Care
        • Fall 18 President's Message
        • Fall 18 Quarterly Progress Report
        • Winter 18 AAHPM News
        • Winter 18 Advocacy Update
        • Winter 18 Annual Assembly
        • Winter 18 Art of Caring
        • Winter 18 Clinical Pearls
        • Winter 18 Ethics
        • Winter 18 Feature
        • Winter 18 Pathways to Palliative Care
        • Winter 18 President's Message
        • Winter 18 Quarterly Progress Report
        • Winter 18 HMDCB Update
        • Spring 19 Editors Message
        • Spring 19 Meet the President
        • Spring 19 Clinical Pearls
        • Spring 19 Art of Caring
        • Spring 19 Advocacy Update
        • Spring 19 Feature
        • Spring 19 Pathways to Palliative Care
        • Spring 19 Diversity and Inclusion
        • Spring 19 Quarterly Progress Report
        • Spring 19 HMDCB Update
        • Spring 19 AAHPM News
        • Summer 19 Presidents Message
        • Summer 19 Clinical Pearls
        • Summer 19 Art of Caring
        • Summer 19 Annual Assembly
        • Summer 19 Advocacy Update
        • Summer 19 Feature
        • Summer 19 Pathways to Palliative Care
        • Summer 19 Ethics and the Hidden Curriculum
        • Summer 19 Research or Quality Improvement
        • Summer 19 Quarterly Progress Report
        • Summer 19 HMDCB Update
        • Summer 19 AAHPM News
        • Fall 19 Presidents Message
        • Fall 19 Clinical Pearls
        • Fall 19 Art of Caring
        • Fall 19 Annual Assembly
        • Fall 19 Advocacy Update
        • Fall 19 Feature
        • Fall 19 Pathways to Palliative Care
        • Fall 19 Diversity, Equity, & Inclusion
        • Fall 19 Quality Improvement
        • Fall 19 Quarterly Progress Report
        • Fall 19 HMDCB Update
        • Fall 19 AAHPM News
        • Fall 19 State of the Science
        • Winter 19 Presidents Message
        • Winter 19 Editor's Message
        • Winter 19 Clinical Pearls
        • Winter 19 Art of Caring
        • Winter 19 Annual Assembly
        • Winter 19 Advocacy Update
        • Winter 19 Feature
        • Winter 19 Pathways to Palliative Care
        • Winter 19 Quarterly Progress Report
        • Winter 19 State of the Science
        • Winter 19 HMDCB Update
        • Winter 19 AAHPM News
        • Spring 20 Presidents Message
        • Spring 20 Meet the President
        • Spring 20 Clinical Pearls
        • Spring 20 Diversity, Equity, & Inclusion
        • Spring 20 Art of Caring
        • Spring 20 Advocacy Update
        • Spring 20 Feature
        • Spring 20 Pathways to Palliative Care
        • Spring 20 Quarterly Progress Report
        • Spring 20 HMDCB Update
        • Spring 20 AAHPM News
        • Summer 20 Presidents Message
        • Summer 20 Meet New AAHPM CEO
        • Summer 20 Annual Assembly
        • Summer 20 State of the Science
        • Summer 20 Clinical Pearls
        • Summer 20 Art of Caring
        • Summer 20 Advocacy Update
        • Summer 20 Feature
        • Summer 20 Pathways to Palliative Care
        • Summer 20 Quarterly Progress Report
        • Summer 20 AAHPM News
        • Summer 20 HMDCB Update
        • Summer 20 PCQC Update
        • Fall 20 Presidents Message
        • Fall 20 Art of Caring
        • Fall 20 Annual Assembly
        • Fall 20 Clinical Pearls
        • Fall 20 Lets Think About it Again
        • Fall 20 Advocacy Update
        • Fall 20 Feature
        • Fall 20 Pathways to Palliative Care
        • Fall 20 Diversity, Equity, & Inclusion
        • Fall 20 Quarterly Progress Report
        • Fall 20 HMDCB Update
        • Fall 20 PCQC Update
        • Winter 20 Presidents Message
        • Winter 20 Annual Assembly
        • Winter 20 Clinical Pearls
        • Winter 20 Lets Think About it Again
        • Winter 20 Art of Caring
        • Winter 20 Advocacy Update
        • Winter 20 Feature
        • Winter 20 Pathways to Palliative Care
        • Winter 20 Diversity, Equity, & Inclusion
        • Winter 20 Quarterly Progress Report
        • Winter 20 HMDCB Update
        • Winter 20 PCQC Update
        • Winter 20 AAHPM News
        • Spring 21 A Message from the CEO
        • Spring 21 Meet the President
        • Spring 21 Clinical Pearls
        • Spring 21 Art of Caring
        • Spring 21 Interview with AAFP President
        • Spring 21 Advocacy Update
        • Spring 21 Feature
        • Spring 21 Pathways to Palliative Care
        • Spring 21 Lets Think About it Again
        • Spring 21 Diversity, Equity, & Inclusion
        • Spring 21 Quarterly Progress Report
        • Spring 21 HMDCB Update
        • Spring 21 PCQC Update
        • Spring 21 AAHPM News
        • Summer 21 A Message from the President
        • Summer 21 Annual Assembly
        • Summer 21 Clinical Pearls
        • Summer 21 Art of Caring
        • Summer 21 Advocacy Update
        • Summer 21 Feature
        • Summer 21 Pathways to Palliative Care
        • Summer 21 Lets Think About it Again
        • Summer 21 Quarterly Progress Report
        • Summer 21 HMDCB Update
        • Summer 21 PCQC Update
        • Summer 21 AAHPM News
        • Fall 21 A Message from the President
        • Fall 21 State of Science
        • Fall 21 Annual Assembly
        • Fall 21 Clinical Pearls
        • Fall 21 Advocacy Update
        • Fall 21 Feature
        • Fall 21 Pathways to Palliative Care
        • Fall 21 Lets Think About it Again
        • Fall 21 Diversity, Equity, & Inclusion
        • Fall 21 Quarterly Progress Report
        • Fall 21 Art of Caring
        • Fall 21 HMDCB Update
        • Fall 21 PCQC Update
        • Winter 21 A Message from the President
        • Winter 21 The Bridge Builder
        • Winter 21 Clinical Pearls
        • Winter 21 Art of Caring
        • Winter 21 Advocacy Update
        • Winter 21 Feature
        • Winter 21 Pathways to Palliative Care
        • Winter 21 Lets Think About it Again
        • Winter 21 Quarterly Progress Report
        • Winter 21 Partner Updates
        • Winter 21 AAHPM News
        • Spring 22 Meet the President
        • Spring 22 Clinical Pearls
        • Spring 22 Art of Caring
        • Spring 22 Advocacy Update
        • Spring 22 Feature
        • Spring 22 Pathways to Palliative Care
        • Spring 22 Lets Think About It Again
        • Spring 22 DEI LAB
        • Spring 22 Quarterly Progress Report
        • Spring 22 AAHPM Partner Update
        • Spring 22 AAHPM News
        • AAHPM Quarterly: Spring 2022 (Full Issue)
        • Summer 22 A Message from the President
        • Summer 22 Clinical Pearls
        • Summer 22 Art of Caring
        • Summer 22 Advocacy Update
        • Summer 22 Feature
        • Summer 22 DEI LAB
        • Summer 22 Quarterly Progress Report
        • AAHPM Quarterly: Summer 2022 (Full Issue)
      • SmartBriefs
    • AAHPM Learn
      • Interactive Activities
    • Self-Study
      • Board Prep Materials
      • Essentials
      • Primer
      • HPM PASS
      • HPM FAST
        • HPM FAST CME
      • Hospice Products
        • HMD Manual
        • HMD PREP
      • Opioid REMS
      • hpmpasscme
      • Opioid Resources
    • Fellowships
      • Competencies
        • Pediatric Competencies
      • Accreditation
      • NRMP Match
      • Grants
        • Ho/Chiang Foundation
      • Hospice Program Toolkit
      • CBME Recordings
    • CME
    • Quality
      • Measuring What Matters
      • Quality Reporting
      • Quality Resources
      • Quality Registries
      • Quality Improvement Education
    • Research
      • Research Funding
      • Successful Research Grants
    • COVID-19 Resources
    • COVID hotel
  • Advocacy
    • Stay Informed
    • Take Action
    • Key Issues
      • Opioids
      • Workforce
  • Career Development
    • Jobs
      • Virtual Career Fair
    • Clinical Training
      • Additional Training
    • Leadership Development
      • AAHPM Ascend
        • Leadership Forum Faculty and Facilitators
        • Ascend Schedule
        • Ascend Facilitators
    • Certification
      • Allopathic
      • Hospice
        • HMDCB Research
      • Osteopathic
    • Continuing HPM Certification
    • Workforce Statistics
    • Scholarships
      • Access Fund
      • Leadership Scholars
      • International Physicians
      • Pediatric Scholarship
      • Research Scholars
      • Next Gen Scholars
    • Resilience and Well-being
  • About
    • History
    • Position Statements
      • Access to Palliative Care and Hospice Position Statement
      • Artificial Nutrition Position Statement
      • Research Ethics Position Statement
      • Palliative Sedation Position Statement
      • Physician-Assisted Dying Position Statement
      • Withholding Position Statement
      • Physician Assisted Dying Position Statement Review
      • Physician-Assisted Dying
    • Talking About HPM
      • Advance Directives-Talking HPM
      • Choosing a Hospice Program-Talking HPM
      • Defining HPM-Talking HPM
      • Explaining PAD-Talking HPM
      • Costs-Talking HPM
      • Withdrawing LST-Talking HPM
      • Choosing Wisely
      • Members Talking About HPM
    • Governance
      • Board of Directors
        • Board Only
        • Past Presidents
      • Committees
      • Staff
        • Staff
      • Call for Nominations
      • Revised Bylaws
    • Giving Center
      • Reasons to Give
      • AAHPM Giving Circle
      • Year End Donations
      • Giving Tuesday Donations
      • Bogetz Educational Fund
      • Donation Form
      • Donation FAQ
    • Awards
      • Visionaries in HPM
      • Emerging Leaders
    • Social Media
  • AAHPM Learn
    • Browse All
    • Books
    • Core Content
    • Self-Study
    • Essentials
  • Legislative Action Center
  • My Account
  • Username & Password
  • Manage Credit Cards
  • Demographics
  • My Classroom
  • Quarterly Newsletter
  • Pay Open Balances
  • Purchase History
  • Membership Details
  • My Communities
  • My Volunteer History
  • Uploaded Documents
  • Writing Instructional Objectives
  • Meetings
    • Leadership Forum: Ascend
    • Annual Assembly
    • State of the Science
    • State of the Science
    • Intensive Review Course
    • Advanced Course in Pain
    • Intensive Board Review Course 2018 Recordings
    • IBRC18 - Additional Management Strategies for Cancer Related Symptoms
    • IBRC18 - Approaches to Care, including Hospice/Medicare
    • IBRC18 - Assessment and Care of the Dying Patient
    • IBRC18 - Communication and Teamwork
    • IBRC18 - Depression/Anxiety & Other Mood Disorders
    • IBRC18 - Ethical and Legal Decision Making
    • IBRC18 - Grief and Bereavement and Spiritual Care
    • IBRC18 - High Yield Pediatrics for the Boards
    • IBRC18 - Non-Pain Symptom Management – GI
    • IBRC18 - Non-Pain Symptom Management – Respiratory
    • IBRC18 - Non-Pain Symptom Management: Pot-Pourri
    • IBRC18 - Pain Management Overview
    • IBRC18 - Palliative Sedation/Physician-Assisted Dying/Discontinuation of Technological Support
    • IBRC18 - Practice Test Question Review Q&A (1)
    • IBRC18 - Practice Test Question Review Q&A (2)
    • IBRC18 - Practice Test Question Review Q&A (3)
    • IBRC18 - Prognostication
    • IBRC18 - Special Topics in Pain Management
    • IBRC18 - Symptom Potpourri
    • IBRC18 - Taking the Test Like a Pro
    • IBRC18 - Urgent Medical Conditions
  • Publications
    • JPSM
    • PC-FACS
    • Quarterly
    • SmartBriefs
  • AAHPM Learn
    • Interactive Activities
  • Self-Study
    • Board Prep Materials
    • Essentials
    • Primer
    • HPM PASS
    • HPM FAST
    • Hospice Products
    • Opioid REMS
    • hpmpasscme
    • Opioid Resources
  • Fellowships
    • Competencies
    • Accreditation
    • NRMP Match
    • Grants
    • Hospice Program Toolkit
    • CBME Recordings
  • CME
  • Quality
    • Measuring What Matters
    • Quality Reporting
    • Quality Resources
    • Quality Registries
    • Quality Improvement Education
  • Research
    • Research Funding
    • Successful Research Grants
  • COVID-19 Resources
  • COVID hotel

Feature

Feature

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.

References

  1. 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.
  2. 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.
  3. Martinsons J. Seeking balance in opioid prescribing. American Academy of Hospice and Palliative Medicine Quarterly Newsletter. 2015 Spring;13:12–15.
  4. 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.

Larry Beresford is a freelance medical journalist in Oakland, CA, editor of the Hospice Compliance Letter newsletter published by Weatherbee Resources, and a contributor on end-of-life topics to the Lancet’s United States of Health U.S. blog page. Contact him at This email address is being protected from spambots. You need JavaScript enabled to view it. .


Go to the table of contents to read more articles.

Essential Practices in Hospice and Palliative Medicine

This comprehensive self-study provides a critical foundation for those who want to incorporate principles of hospice and palliative medicine into their daily lives.

Learn More

Quick Links

  • Job Mart
  • JPSM
  • CME/CE Certificates
  • Purchased Activities
  • Terms and Conditions
  • Privacy Policy

For Exhibitors and Advertisers

  • Commercial Support
  • Exhibiting
  • Advertising
  • Mailing Labels

For Students and Residents

  • Membership
  • Careers
  • Fellowships
  • Publications
Facebook Twitter Linked In Visit our patient website: PalliativeDoctors.org

AAHPM Logo

8735 West Higgins Road, Suite 300 Chicago, IL 60631

Phone 847-375-4712 Fax 847-375-6475 E-mail info@aahpm.org

Copyright © American Academy of Hospice and Palliative Medicine