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November 27, 2017


Pain and anesthesia groups should document their opioid prescribing practices with extra care in the current climate, which is marked by ongoing investigations by the Office of Inspector General and the Department of Justice’s Opioid Fraud and Abuse Detection Unit.  We share a documentation checklist for existing chronic pain patients from the newsletter of the Health Care Compliance Association.  We also present an educational framework for clinicians regarding screening for opioid use disorder, prescribing, use of naloxone, access to treatment and understanding the stigma surrounding the disorder.

Citing eye-opening statistics from the American Society of Addiction Medicine indicating 52,404 fatal drug overdoses in 2015, healthcare leaders are calling for a multi-pronged effort in combatting the opioid epidemic in America.  With their deep pharmacological expertise and clinical experience, anesthesia providers and pain specialists are eminently qualified to initiate and play a central role in such efforts at their institutions.  This eAlert explores a framework for education as an essential component of these collaborations.  But first, we offer an attorney’s recommendations regarding steps anesthesia providers and pain specialists can take to document compliance carefully in a time of heightened governmental scrutiny.

Manage Your Risk

In light of the recent declaration by President Trump of the opioid crisis as a national public health emergency and ongoing investigations of opioid prescribing practices by the Office of Inspector General and the Department of Justice’s Opioid Fraud and Abuse Detection Unit (see our November 6, 2017 eAlert), anesthesia providers, pain specialists and their institutions would be wise to pay careful attention to their documentation in this area.  “Providers need to implement compliance measures to protect their prescribers from enforcement activity because, despite the Department of Justice’s rhetoric, prescription opioids are often clinically appropriate for chronic pain management,” attorney Jeff Fitzgerald said in the July issue of the Health Care Compliance Association’s Report on Medicare Compliance.  He recommended that physicians also document reviews of opioid prescriptions for new patients and new injuries/pain. 

Mr. Fitzgerald offered the following chronic pain documentation checklist for existing patients, noting that a separate process should be developed for new patients and new injuries/pain:

Existing Chronic Pain Patient Checklist

Source:  Report on Medicare Compliance, Health Care Compliance Association, July 2017.

Hospital Partnerships

In an article in NEJM Catalyst, a publication of the New England Journal of Medicine, Jay Bhatt, DO, and Elisa Arespacochaga of the American Hospital Association assert that while the patient-clinician partnership represents the core of the solution to the opioid crisis, “all stakeholders, including healthcare organizations, state and local health departments, law enforcement agencies, schools and community organizations need to work together to affect change.  Hospitals and health systems must fully support clinicians in helping connect patients to resources, treatment and the help they need.  Hospitals and health systems could support clinicians in connecting patients to social support and appropriate treatment.”  Anesthesia providers and pain specialists are ideally positioned to serve as key members of the educational and change management team.

New findings suggest that collaborations like those encouraged by Dr. Bhatt and Ms. Arespacochaga are urgently needed.  A report released this month by the White House’s Council of Economic Advisers indicates that America’s opioid crisis cost the U.S. economy more than $500 billion in 2015, far more than previously believed.

Noting that “how clinicians provide care to patients who are opioid-dependent or have overdosed, how they think about and prescribe opioids, how they connect patients to treatment resources, and how well they are collaborating with other stakeholders in this work are all key to better treatment, results, and recovery,” Dr. Bhatt and Ms. Arespacochaga encourage education in five areas for clinicians, including medical students and residents.  They are:

Patient screening.  “The first step in confronting the opioid epidemic is recognizing the disease,” they assert. They cite key risk factors, including a history of substance use disorder, chronic pain and mental illness. White males from rural or lower socioeconomic backgrounds also suffer disproportionately from opioid use disorder. They urge providers to use one of the several effective screening tools to identify at-risk patients, including the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) guide, Screening, Brief Intervention, and Referral to Treatment or the National Institute on Drug Abuse (NIDA) Drug Screening Tool

ABC’s July 24, 2017 eAlert also describes a five-question shorter version of the Current Opioid Misuse Measure (COMM) screening tool, presented at ANESTHESIOLOGY® 2016. Data suggest the abbreviated tool can be used to quickly and efficiently identify opioid-related aberrant behavior that might indicate abuse or addiction.

Appropriate prescribing practices.  Clinicians should have ready access to leading-edge resources, including prescribing guidelines, patient education materials, and information on non-opioid alternatives for pain management.  These resources include: 1) a Centers for Disease Control and Prevention/AHA handout,  “Prescription Opioids: What You Need to Know,” that supports effective clinician-patient communication about opioid risks and alternatives; 2) “Taking Opioids Responsibly for Your Safety and the Safety of Others,” a guide from the Department of Veterans Affairs National Pain Management Program that provides information on the hazards of long-term opioid therapy; 3) a CDC webinar for clinicians on applying the principals of motivational interviewing called “Effectively Communicating with Patients About Opioid Therapy”; and 4) educational materials from the Institute for Safe Medication Practices on 11 high-alert medications, including oxycodone.  Dr. Bhatt and Ms. Arespacochaga also suggest that hospitals consider monitoring prescribing practices and reviewing findings periodically to help clinicians understand how they can improve.  Anesthesiologists, nurse anesthetists and pain specialists might consider spearheading such efforts in cooperation with hospital clinical and administrative leaders. 

Recommended resources on alternatives to opioids include: 1) the CDC webinar, “Recommendations for Non-Opioid Treatments in the Management of Chronic Pain”; and 2) the Alternatives to Opiates Program developed by St. Joseph’s Regional Medical Center in Paterson, New Jersey, which uses trigger point injections, ultrasound-guided nerve blocks and other alternative therapies in tailoring treatment.

The American Society of Anesthesiologists (ASA) and Premier, Inc. have launched a national pilot called the Safer Postoperative Pain Management program focusing on adult patients undergoing elective hip and knee arthroplasty and colectomy surgical procedures.  The program’s goals are to help clinicians develop best practices and workflows around the safer use of opioids in pain management.  These strategies include discussing pain management expectations with patients and families, education on safe opioid use, storage and disposal, and opioid misuse and abuse prevention following hospital discharge.   

Access to naloxone.  Access to this medication, which has reversed more than 26,000 opioid overdoses, should be more affordable and widespread, and hospitals can partner with law enforcement agencies and community organizations to facilitate this expansion, the authors contend.  (See also the statement by the ASA Committee on Pain Medicine encouraging physicians to consider co-prescribing naloxone with an opioid for patients at high risk of overdose.)

Access to treatment.  Medication-assisted treatment (MAT), which uses a combination of medications, counseling and behavioral therapy, shows promise as an approach to opioid use disorder, and more clinicians should be trained in its use. 

MAT resources include: 1) SAMHSA’s free pocket guide for physicians, “Medication-Assisted Treatment of Opioid Disorder”; 2) a national training and clinical mentoring project called Providers’ Clinical Support System for MAT (PCSS-MAT); 3) Project ECHO – Opioid Addiction Treatment, for family nurse practitioners and physician assistants; and 4) an AHA case study, Tackling the Opioid Crisis in a Rural Community, which presents the story of how Bridgton Hospital in Maine used MAT with excellent results.

Understanding bias and stigma.  Opioid addiction affects people of all ages, races and socioeconomic backgrounds, but some clinicians carry erroneous assumptions about what an opioid addict “looks like.”  Resources to help educate providers in this area include:  1) Colorado ACEP 2017 Opioid Prescribing & Treatment Guidelines, which address the topic of stigma; 2) Addiction, Stigma and Discrimination: Implications for Treatment and Recovery, a webinar on reducing stigma and enhancing the quality of care; and 3) The Role of Shame in Opioid Use Disorders, an online educational module.  

The AHA has also developed a toolkit offering guidance and case examples to help hospitals and health systems work with patients, clinicians and communities to combat the opioid crisis.

More Resources
Reversing the Opioid Epidemic:  resources from the American Medical Association’s Opioid Task Force, including information on prescription drug monitoring programs, increasing access to naloxone, CME courses on opioids and addiction, reducing the stigma of substance use disorders, and storage and safe disposal of opioids and other prescription medications.

HHS Opioid Code-a-thon, an initiative of the Department of Health and Human Services that will join public health experts, data scientists, computer programmers and researchers in small teams to develop data-driven solutions to combatting the opioid epidemic.  The Code-a-thon will be held on December 6 and 7, 2017.

With best wishes,

Tony Mira
President and CEO