SAFE GC Coalition: Opioid Epidemic and Health Policy Initiatives

An article published last month in the National Institutes of Health (NIH) National Library of Medicine discussed the opioid epidemic, surgeon’s contribution to it and health policy initiatives. Opioid abuse and addiction is causing widespread devastation in communities across the USA and resulting in significant strain on the nation’s healthcare system. There is increasing evidence that prescribers are at least partly responsible for the opioid crisis because of over prescribing, a practice that developed from changes in policy and reimbursement structures.

Surgeons, specifically, have been subject to scrutiny as adequate treatment of post-surgical pain is poorly defined and data suggest that many patients receive much larger opioid prescriptions than needed.

The consequences of over prescribing include addiction and misuse, dispersion of opioids into the community, and possible potentiation of illicit drug/heroin use. Several solutions to this crisis are currently being enacted with variable success, including Prescription Drug Monitoring Programs, policy-level interventions aimed to de-incentivize overprescribing, limiting opioid exposures through Enhanced Recovery After Surgery protocols, and the novel idea of creating surgery- and/or procedure-specific prescribing guidelines.

This problem is likely to require not one, but several potential solutions to reverse its path. The article states that it is critical, however, that physician and prescribers find a way to stop the needless over prescribing while still treating postoperative pain appropriately.

According to the article, prescribers represent the only source of legal opioids that are introduced into the community. Twenty years of prescribing data were analyzed demonstrating a fourfold increase from 1999 to 2008, which was associated with a fourfold increase in deaths attributable to prescription opioids over the same time period. There were enough prescription opioids dispensed in 2015 to medicate every US adult with 5 mg of hydrocodone every 4 hours for 3 weeks.

When compared with healthcare systems globally, the USA prescribes 50 times more opioids than the rest of the world combined which may explain why the opioid crisis has not reached the same magnitude in other parts of the world. This data indicates U.S. clinicians are prescribing opioids at increasingly high rates although the peak has plateaued. The researchers feel that efforts to understand and define the driving forces behind this phenomenon are vital to reversing the process.

According to the article, there are three system wide reasons why opioid prescribing has been increasing at this alarming rate. First, there was a historic failure to address acute pain in hospitalized patients and pain management experts were alarmed at this. These experts argued that because pain was not a visible part of a patient’s chart, physicians were not held accountable for treating pain. In the 90s The American Pain Society fashioned patients’ pain to a “fifth vital sign” and encouraged increased prescribing practices.

A second contributing factor relates to reimbursement and physician/hospital quality ratings when patients were asked post discharge questions about their hospital stay. An example is from the Center for Medicare and Medicaid Services (CMS) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The survey was implemented in October 2006. Within the original 32-item survey, there were three questions dedicated to how well the patients’ pain was managed.

The results of this survey are publicly reported, allowing patient comparison between hospitals. Results are also linked to CMS payments through the Value-Based Purchasing program. With this additional measure emphasizing the importance of pain management, one could assume that prescribers more readily provided increasing amounts of opioids in the hospital setting and on discharge.

Lastly, the authors maintain restrictions on opioid prescribing may paradoxically perpetuate overprescribing. Patients require a handwritten prescription from physicians to obtain Schedule II substances. These prescriptions cannot be electronically signed or faxed to a patients pharmacy. This category of substances includes commonly used opioids such as morphine, oxycodone, hydromorphone, methadone and hydrocodone.

As a result, if patients need a refill of these medications, they must physically return to their physicians office to obtain another prescription. This can be quite inconvenient for the patient and prescriber, especially in tertiary care hospitals where patients often travel far distances to receive their care. To avoid such inconveniences, prescribers may prescribe opioid even when the degree of pain is anticipated to be minimal or prescribe more than necessary “just in case.”

Opioid abuse and misuse has reached epidemic proportions and surgeons have contributed to the problem with excessive opioid prescribing. Several factors have contributed to the culture of over prescribing, including increased emphasis on aggressive pain control, ties to reimbursement, and the need to physically hand opioid prescriptions to patients.

Even small exposures to opioids can result in addiction and chronic use, with excess pills becoming dispersed into the community and perpetuating the crisis. Several solutions have been proposed and implemented, but an important active area of research is development of procedure-specific prescribing guidelines. These system-wide and provider-level initiatives can mitigate misconceptions that opioid use at the time of surgery is benign and change the longstanding culture of over prescribing.

The National Institutes of Health (NIH) is a part of the U.D. Department of Health and Human Services. NIH is the largest biomedical research agency in the world. For more information please visit www.nih.gov.

The SAFE Glen Cove Coalition is conducting an opioid prevention awareness campaign entitled, "Keeping Glen Cove SAFE," in order to educate and update the community regarding opioid use and its consequences. To learn more about the SAFE Glen Cove Coalition please follow us on www.facebook.com/safeglencove or visit SAFE’s website to learn more about the Opioid Epidemic at www.safeglencove.org.