E-Prescribing and Other Opioid-Related News for Pain and Anesthesia Practitioners
SUMMARY Despite some small signs of progress, the opioid epidemic remains a serious reality in the United States, with recent survey data showing that one in three patients who have taken prescription opioids for at least two months report addiction or psychological dependence. An article by Atul Gawande, MD, MPH, in the April 2017 issue of Annals of Surgery calls on physicians to advocate for and begin using electronic prescribing to stem the flow of opioids and help protect against abuse, misuse and diversion.
Recent data regarding opioid-related deaths tell some harsh truths about the depth of opioid addiction in the United States. In December, the Centers for Disease Control and Prevention (CDC) reported that the number of overdose deaths involving opioids rose from 28,647 in 2014 to 33,091 in 2015—an increase of nearly 5,000 deaths and the first time deaths in one year exceeded 30,000.
A small ray of hope came from the finding that overdose deaths involving prescription opioids rose a comparably low four percent, from 16,941 in 2014 to 17,536 in 2015, suggesting, according to the CDC, that "efforts in recent years to reduce the misuse of these drugs may be having an impact." Also, before leaving office, President Barack Obama allocated $1 billion for much-needed opioid treatment through the 21st Century Cures Act. And, as noted in our December 27, 2016 eAlert, opioid prescriptions fell by 10.6 percent between 2013 and 2015 with increasing physician awareness of opioid abuse, improvements in opioid prescribing practices and expanded access to naloxone. Physicians checked state prescription drug monitoring programs (PDMPs) nearly 85 million times in 2015, a 40 percent increase from the previous year.
Still, while these small steps offer glimmers of progress, deaths related to synthetic opioids rose an astonishing 73 percent in 2014-2015. Heroin deaths actually surpassed gun homicides for the first time.
As anesthesia providers well know, patients who receive prescription opioids for acute and chronic pain risk becoming addicted. These risks must be balanced against the potential benefits of opioid medications for patients who are in severe discomfort. "We're not saying that no one should ever be on these pills," but most people would be "healthier and more functional if they were off them," CDC Director Tom Frieden said in the Washington Post. "The bottom line here is that prescription opiates are as addictive as heroin. They're dangerous drugs. You take a few pills, you can be addicted for life. You take a few too many and you can die."
E-Prescribing Emerges
As the physicians who write more opioid prescriptions than any other specialty, pain specialists and anesthesiologists have good cause to give serious weight to the potential for opioid misuse and abuse among their patients. As participants in the nationwide multi-specialty Choosing Wisely campaign to reduce the unnecessary use of procedures, tests and treatments, the American Society of Anesthesiologists now recommends that physicians avoid prescribing opioids as first-line therapy or as long-term therapy for chronic non-cancer pain.
One-third of patients who took prescription opioids for at least two months reported being addicted or psychologically dependent, according to a Washington Post-Kaiser Family Foundation survey. Virtually all long-term users said they were introduced to the drugs through a prescription, not by friends or through illicit means. And although 78 percent of patients said their physicians warned them not to mix the pain relievers with alcohol, only 33 percent said their doctors discussed a plan with them for stopping the medication.
Recently, the use of electronic prescribing has gained recognition as a tool to guard against opioid abuse, misuse and diversion among patients. In an article in the April issue of Annals of Surgery, surgeon and author Atul Gawande, MD, MPH, urged physicians to embrace e-prescribing to help avoid opioid over-prescribing and curb the opioid crisis. Though his comments are directed to surgeons, his suggestions might well apply to anesthesia providers, pain specialists in particular.
E-prescribing systems can help reduce dosing errors; facilitate cross-referencing with PDMPs; and streamline prescribing processes for physicians, making it easier to write smaller prescriptions and order an additional supply if a patient needs more, Dr. Gawande argues. The two-factor authentication required for e-prescribing of controlled substances can also help prevent duplicate and forged prescriptions. (The state of New York now requires e-prescribing for controlled substances.)
Stemming the Tide
Dr. Gawande cites new data from Dartmouth Hitchcock Medical Center also published in the April issue of Annals showing a pattern of opioid over-prescribing among surgeons. Seventy-two percent of the opioid pills prescribed by surgeons for five common surgical procedures were unused. One hundred seventeen of 127 patients had excess pills, and three-fourths kept the pills rather than disposing of them. Since opiate abusers often obtain their drugs through diversion, "surgeons are proving to likely be a significant source of the opioid supply fueling the current epidemic," Dr. Gawande writes.
An analysis of data on 11.3 million patients from the National Inpatient Sample, also published in the April Annals, indicates that the rate of postoperative opioid overdoses has nearly doubled in the past decade from 0.6 to 1.1 cases per 1,000 patients per year, with a history of substance abuse as the single greatest predictor. Although postoperative overdose (OD) is still rare, it is rising. According to the authors:
The risks of postoperative OD must be weighed against the benefits afforded by adequate pain control in the postoperative setting. Identifying patients at highest risk for postoperative OD is imperative to ensure that appropriate monitoring is provided. Because almost all devastating injuries from postoperative OD are avoidable, early identification of this complication is crucial to allow providers time to intervene. Findings from this study should be used by all perioperative care providers to ensure that patient's discomfort is treated in an appropriate and safe manner.
Complicating these problems is the fact that surgeons lack guidelines for their opioid therapy decisions and tend to prescribe amounts to meet the needs of the vast majority of patients in order to avoid situations in which patients are left in severe pain after discharge and unable to obtain a written prescription. The authors of the Annals study suggest the number of opioid pills sufficient for the pain management needs of the majority of patients undergoing five common procedures, noting that the amounts are significantly smaller than the numbers surgeons typically prescribe. These include five pills following partial mastectomy and 15 pills following laparoscopic cholecystectomy. They write:
Overprescribing opioids would be acceptable if the cost of opioid prescriptions to individual patients and the cost to society were negligible. However, the current epidemic of deaths from opioid overdose, largely fueled by diversion of prescription opioids, makes it clear that the cost to society is not negligible, and must be considered when prescribing opioids for individual patients. In an attempt to balance this societal mandate and the need to satisfy the analgesic needs and minimize the inconvenience of returning for refills for most patients, we felt that satisfying 80 percent of patients' opioid requirements with the initial prescription was reasonable. Using this as a best practice guideline, we have shown that we can decrease the number of opioid pills initially prescribed for common general surgical operations to 43 percent of the number actually prescribed.
They also suggest the following prescribing practices:
- Counsel patients preoperatively to expect adequate pain control to function (e.g., sleep, eat, ambulate) but not to achieve zero pain. (Function is a better indicator than pain level.)
- Use nonopioid alternatives for patients undergoing procedures with only mild pain.
- Check the state's prescription monitoring program database to confirm that the patient is not receiving opioids through other clinicians.
- Provide clear disposal instructions. (The FDA's recommended methods of disposal are to flush unused opioids down the toilet, or to bring to a pharmacy or other approved disposal sites.)
- Prescribe the "minimum quantity necessary."
It is for this last recommendation that e-prescribing can be particularly valuable, according to Dr. Gawande. However, although the technology is readily available, with 81 percent of pharmacies equipped to receive e-prescriptions for controlled substances and more than 90 percent of physicians using electronic medical records, most of which can be enabled for e-prescribing, only eight percent of physicians take advantage of the functionality, he said.
Dr. Gawande urged surgeons [physicians] to advocate for the adoption of e-prescribing in their institutions to "stem the massive oversupply of prescription opioids while still meeting patients' pain needs."
We hope this information sparks a discussion with your surgical colleagues and helps you weigh the merits of e-prescribing in your own practices and institutions.
With best wishes,
Tony Mira
President and CEO