The Doctor’s Advocate | Second Quarter 2017
Opioids play an important role in pain management—both in acute and chronic settings. Prescribing safely is a laudable goal for healthcare providers, especially considering that 60 percent of Americans over age 65 seek relief from persistent pain. However, the dramatic increase in opioid use over the past few decades has resulted in an opioid-related epidemic of addiction and death. There has also been substantial misuse of opioids obtained by diversion—that is, by a person for whom they were not prescribed.
Consider these facts:
Poor patient outcomes related to opioids are a common cause of litigation. The Doctors Company studied 272 claims that closed between 2007 and 2015 in which opioids resulted in patient harm. Contributing factors included:
Prescription opioids (mu receptor agonists) are no less addictive than heroin, and the increase in prescription opioids fuels illicit drug use. The dramatic increase in heroin addiction and related deaths has accelerated as a result of the low street price of heroin, compared to the relatively high cost of Percocet (New York Times, June 14, 2016).
While physicians prescribe many medications with high risk/benefit ratios and a narrow therapeutic window, the high opioid complication rate is unique—largely because opioids induce euphoria, have a high potential for addiction, and have a therapeutic endpoint (i.e., suppression of pain) that is subjective. Healthcare providers must work to prevent opioid misuse and addiction while protecting the well-being of patients experiencing the devastating effects of acute or chronic pain.
In March 2016, the Centers for Disease Control and Prevention (CDC) published guidelines for prescribing opioids for chronic, noncancerous pain. The following is a distillation of these guidelines, with recommendations from other sources:
Many state medical boards across the country require documentation of the following when prescribing opioids:
In summary, it is possible to prescribe opioids responsibly and safely for patients with chronic pain who do not obtain sufficient relief and reasonable function with nonopioid treatment. However, to do so, it is necessary to have adequate knowledge of the pharmacology of opioids, risk factors, and side effects. Safe opioid prescribing requires thorough patient evaluation, attention to detail, and familiarity with guidelines and regulations.
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States. JAMA. 2016;315(15):1624-1645.
Frieden TR, Houry D. Reducing the risks of relief—the CDC’s opioid prescribing guideline. N Engl J Med. 2016 Apr 21;374(16):1501.
Extended release/long acting opioids: achieving safe use while improving patient care. (CO*RE Collaboration for REMS Education 2013.)
Interagency guideline on prescribing opioids for pain. Olympia, WA: Washington State Agency Medical Directors’ Group; 3rd Edition. 2015. www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf/Files/2015AMDGOpioidGuideline.pdf.
Pevoznik T. The heart of safety. Paper presented at: 18th Annual NPSF Patient Safety Congress; May 23–25, 2016; Scottsdale, AZ.
Califf RM, Woodcock J, Ostroff S. A proactive response to prescription opioid abuse. N Engl J Med. 2016 Apr 14;374(15).
Renthal W. Seeking balance between pain relief and safety: CDC issues new opioid-prescribing guidelines. JAMA Neurol. 2016;73(5):513-514.
Vestal C. States require opioid prescribers to check for “doctor shopping.” Stateline. Pew Charitable Trusts. May 9, 2016. www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/05/09/states-require-opioid-prescribers-to-check-for-doctor-shopping.
Kennedy-Hendricks A, Gielen A, McDonald E, McGinty EE, Shields W, Barry CL. Medical sharing, storage, and disposal practices for opioid medications among US adults. JAMA Intern Med. 2016;176(7):1027-1029.
Ray WA, Chung CP, Murray KT, et al. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.
The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.
The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.
The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.
Second Quarter 2017
From the Chairman
2017 Member Dividend Announced
Prescribing Opioids Safely
An Ounce of Prevention
The Doctors Company Introduces a New CME Series
Government Relations Report
Federal Medical Liability Reform: A Historical Perspective
The Doctors Company Foundation Changes Leadership
Innovations in Patient Safety
Data-Driven Insights: Fear to Act in Obstetrics