Ultimately, the opioid crisis gripping America today is about pain.
More specifically, it’s about how we as medical professionals address pain, representing a shift in philosophy over the last several years. Rather than apply the same guidelines to opioids that we apply to antibiotics — Is there a legitimate medical purpose for these drugs? What are the professional standards that doctors apply to prescribing them? What is the metric for determining the correct amount? — too many doctors have bypassed those critical questions because someone gave us an easy solution.
As shown in many recent news reports, drug manufacturers are seeking profit at the expense of patient lives. Whatever punishment is handed down by the government, chances are it won’t really affect a pharmaceutical company’s ability to operate; on the other hand, when doctors are arrested and punished for unlawful distribution of opioids, as happened in Pittsburgh recently, it essentially ends their business.
This underscores the personal and professional responsibility that we, as doctors, must uphold for the good of our patients — beyond the consequences that individual physicians may face. Massachusetts, where I’m based, is seeing four people per day die as a result of opioid addiction.
Put simply, our ability as doctors to stem the tide of opioid overprescribing is literally a matter of life and death.
What can providers do?
Healthcare professionals who interact with patients at their most vulnerable need to take the time to ask questions that most accurately identify what’s happening with them.
Take the typical question about pain: We offer patients a scale from 1 to 10. But different patients have different, subjective ideas of what a “5” or a “9” means — and if a medical provider prescribes the same course of opioids for two people reporting the same number on the scale, we’re basically ignoring their subjective views.
Instead of the 1-to-10 scale, doctors can consider questions like those we ask in other situations. For example, we ask patients about family history of diabetes — why couldn’t we, then, ask about family history of addiction?
We can also ask whether any person sharing the patient's living space is currently taking opioids, since that increases the potential for abuse. In addition, driving directly at the core of our role as medical providers, we need to consider the risks, benefits, and any alternatives to prescribing opioids to each individual.
In other words, doctors need to adapt the clinical pathways that govern the use of other medications.
Beyond that, doctors should also be accountable to government oversight regimens like the Prescription Monitoring Program that Massachusetts and 30 other states have created. These programs create a report card on area physicians and their opioid prescribing habits.
What we’ve seen in Massachusetts is a reduction of nearly half in the incidence of “Individuals with Activity of Concern,” or doctors who appear to be prescribing opioids at too high a volume, from 14.7 per 1,000 in 2013 to 7.7 per thousand in 2016.
Making such independent oversight mandatory in all 50 states may also make a significant impact on providers who may otherwise prescribe opioids without more careful review.
Evolving along with healthcare trends
In the past, pain control wasn’t really the biggest factor in post-surgical care; physicians focused on whether the patient survived the surgery and if the procedure achieved the desired results.
Over time, though, and particularly with the Joint Commission’s focus on pain, we’re incentivizing outcomes — like pain control — but no one’s looking at the steps necessary to achieve pain control.
What if we rewarded the time it takes to complete a careful pre-opioid prescribing questionnaire, for example? We’d give doctors the leeway to decide whether that would be best for the individual patient.
As healthcare undergoes a revolution in terms of standards and uniform practices, physicians have come to understand the importance of using evidence to tailor each patient’s care to their own needs.
When it comes to the standard for pain care, we’re writing it as we go, and we have to write it faster.
As I explain in a Doctor’s Hours podcast, MEDITECH is developing EHR solutions that support the provider’s decision-making process when prescribing opioids. This support will include alerts to potential drug-drug interactions, electronic checklists to reduce the risk of adverse drug events, and real-time updates to subsequent healthcare practitioners who may eventually contribute to the patient's care plans.
This kind of clinical decision support — along with efforts by doctors to establish and maintain clear standards for prescribing opioids — can help us address what The New York Times calls the deadliest drug crisis in American history.
Interested in how nurses and nurse leaders are navigating the opioid epidemic? Read our special report.