"Pressured": Statistics Regarding the Physician's Look on Prescribing Opioids

Prescription of opioids can sometimes be seen as a requirement in order to guarantee patient satisfaction. Emergency Department (ED) physicians face a difficult challenge when it comes to assessing appropriate management of patients exhibiting “drug seeking” behavior, mainly due to lacking development of continuing medical education and standardized regulatory and legislative protocols. ED physicians were surveyed (n = 141) and 71% reported a perceived pressure to prescribe opioid analgesics to avoid administrative and regulatory criticism. Meanwhile, 98% related patient satisfaction scores as being too highly emphasized by reimbursement entities.

Figure 1: Utilization of opioid abuse identification methods

In Figure 1, the physicians were asked asked about the five methods of opioid abuse identification: physical examination, history, use of the (electronic medical records) EMR, query of the states’ prescription drug monitoring program (PDMP) database, and drug screening. It’s shown that a physical exam, history checks, and use of the EMR are almost always a preferred method amongst physicians in order to identify opioid abuse, however, drug screens seem to be the least utilized method.

Figure 2: Drug screen availablilty for opioids

Drug screen availability is important when trying to assess a patient who is suspected of opioid abuse, misuse or even of “doctor shopping” for different prescriptions. In Figure 2, only 25% of the respondents had the ability to screen for synthetic opioids in their respective ED's. This limitation could severely impact the ED’s ability to determine a patient’s health status. Testing for synthetic opioids required submission to the hospital laboratory according to 29% of the respondents and 33% had to send samples to an outside laboratory. As mentioned before, this severely limits a physician’s ability to diagnose a patient correctly in order to bring them the best care without accidentally contributing to it in a negative way.

As seen in Figure 1, the use of drug screens for proper diagnostics is rarely employed. Meanwhile, in Figure 2, the drug screening availability seems to be limited in many ED’s. In Figure 3, the participants were asked how regulatory and administrative factors affected their opioid prescribing practices. A majority (72%) felt pressured to prescribe in order to avoid administrative complaints from the patient that pain was inadequately treated.

Figure 3: Perceived pressures to prescribe opioids

Another phenomenon observed in opioid addicts is the so-called “doctor shopping”. What this means is that a person will go to several doctors in order to receive different medications, or to get the response they most want (in this case the prescriptions). Most of the participants stated a lack of clarity on the issue or course of action (Figure 4). An alarming response would be that many (52%) disagree that a failure to report this type of behavior would result in civil liability. Another worrying fact, is that 86% of the participants agreed that hospitals don’t provide protocols for this type of behavior, meaning that there is no established method for dealing with this behavior and there may not be an overall surveillance to make sure that physicians don’t help worsen the condition these patients might be in.

Figure 4: Physician course of action when “doctor shopping” indicated

As seen by Figure 5, most of the participants (98%) believed that patient satisfaction scores should not be used as a metric to assess quality patient care. The heavy weight given to satisfaction scores is a main problem in the opioid epidemic because many patients with opioid addiction, or those who misuse opioids, will give a bad score to any physician who doesn’t meet their demands. In turn, this will make physicians care more about their satisfactory rates and lean more towards overprescribing in order to not get in trouble with their administration.

Figure 5: Emphasis on patient satisfaction scores

Overall, the results of this study have identified gaps in training, regulation, and administrative healthcare practices regarding management of patients with a drug-seeking behavior. They’ve also helped to point out many of the attitudes and positions the physicians have themselves regarding the safety and opinion of their patients.

Medically Assisted Treatments and their Effectiveness

The war on opioids has been an uphill battle since they were marked as a Type 2 Schedule on the Schedule of Controlled Substances according to the Controlled Substances Act of 1970. According to the U.S. Government, drugs in this category have a high abuse potential with severe psychic or physical dependence liability. This is now more clear than ever due to the rampant opioid epidemic that has been going on worldwide. As a means to treat those who have become victims, synthetic opioids have been created which can substitute stronger drugs and eventually be completely eliminated. This allows a person suffering from opioid use disorder to limit or eliminate the drug’s consumption.

Currently, there are three primary drugs in the medication-assisted treatment such as: methadone, Buprenorphine and Naltrexone. Methadone is an opioid agonist so it is capable of providing the same effects as regular opioids. Yet this drug lasts in the human body for far longer periods of time while providing a weaker analgesic effect than common narcotics which makes it a great option to treat opioid dependence. Buprenorphine is an opioid agonist as well yet it is mainly used when withdrawal symptoms have recently appeared. It can remain in the body even longer than methadone. And lastly, naltrexone is an opioid antagonist which isn't as long lasting as the other treatments but an extended-release version has been created since it has proved to be quite effective.

There are countless studies to address this issue. To better understand the increase in opioid consumption, data has been recollected by different means of people who were suffering from opioid use disorder, people who were under treatment or those whose death was related to opioids.

One study consisted on using carefully selected data from PubMed and Embase databases using keywords related to analyzing them in order to study the effectiveness of the aforementioned opioids as a method of treatment. The methodology to obtain data that could be used to scrutinize the data is presented as Figure 1. The analysis focused on studying the mortality rate of people not receiving any treatment and those who were under treatment yet with different drugs. There were 21 studies focusing on the effects of drug consumption, there was a 0.92 per 100 person-years of crude mortality rate while receiving medicated-assistance, a 1.69 after cessation and a 4.89 for those untreated. There was another analysis done with 16 studies to obtain a clearer conclusion. Based on the crude mortality rate per 100 person-years of the 16 studies, the following conclusions were drawn: there was a 0.24 while receiving medically-assisted treatment, 0.68 after treatment cessation, and 2.43 for those who were untreated. On the 21 studies which focused on all-cause deaths, those who were on MAT with methadone or buprenorphine were 0.93 and 1.79, meanwhile naltrexone were 0.26.

Another statistical analysis provided even more information about the effectiveness of the opioid agonists, buprenorphine and methadone. The databases used were: Cochrane Drugs and Alcohol Review Group, Cochrane Register of Controlled trials, MEDLINE, EMBASE, Current Contents, PsycLIT, CORK, Alcohol and Drug Council of Australia, Australian Drug Foundation, Centre for Education and Information on Drugs and Alcohol and Library of Congress. Through them, it was possible to obtain 31 trials of 5430 participants. The risk ratio was calculated for each treatment at different concentrations (low, medium and high) to see if there was a correlation between the consumption. It was concluded that buprenorphine at any dosage was more effective than the placebo. It was also stated that methadone was more effective in retaining people in treatment than buprenorphine.

Possible Government's Response towards the Opioid Epidemic:

Possible Government's Action towards the Opioid Epidemic:

Knowing the statistics and where the government stands in the epidemic is useful in order to understand the importance and urgency of the matter. Every person that are in the politics, healthcare and law setting know that they should put a little effort in resolving the issue at hand. It is the only way to combat the epidemic. This is known by the example of Washington State. They made an effort to understand the gravity of the situation in their area since they know that states play a central role in protecting public health and public safety (Franklin 2015). The state has the responsibility of regulating, paying and managing health care. This is why they concluded that as a state, had a critical role in acting as the main way to reverse the prescription drug overdose epidemic.

To start, they made a study to understand the origins of the epidemic in their region, documenting a linear relationship between mortality and sales of a specific prescription opioids, by doing this they understood that the opioid prescribing practice was the main pathway of the epidemic. The first step in order to make an effort to recovery was to make an effective communication in the patient review and coordination program. Here, the goal was to provide the prescription history of the patient to prescribing providers, while identifying when risky behaviors occurred prior medical authorization. This programs was aided by a mental health treatment, and the results of participants where little but hopeful: a decrease of 33% in emergency departments visits and 37% in office visits; and 24% decrease in controlled substance prescriptions. This prompted the first guidelines of opioid dosing in which the stated the limits of morphine equivalent dosing about 120 milligrams per day (mg/d). The guideline had two parts: the first one being focused in naive patients which received a dose lower than 120 mg/d while the second one focused in patients already in in the stated limit dose.

After these guidelines, another were made by an emergency physician in which there was an encouragement to use an Emergency Department information exchange, where the departments could exchange information in real time. This came resourceful after a the bill passed in 2010, in which it was accomplished two key points: repealing the earlier permissive pain rules by the development of new rules had to address opioid dosing criteria, guidelines in pain specialty consultation, guidance in tracking clinical progress and adherent use of opioids. Some recommendations for the emergency departments were to limit the opioids prescription for chronic pain to a single provider; and discourage the administration of them intravenously and intramuscularly as relief for pain.

After these actions were taken, the state evaluated themselves and noticed improvements. They didn't stop with these actions, therefore they looked for improvement in order to achieve the best outcome possible. They gave free educational consultations as modeled by the University of New Mexico in which the consultations were given by a multidisciplinary group of pain experts and focused on management of chronic pain and addiction-dependence issues1. The guidelines once followed were edited to lower the morphine equivalent dose from 120 to 80 and 100 mg/d. This parametric were accepted by the practicing physicians since they were made from a collaboration of public agencies, clinical and academic pain leaders. Also, a law was passed in relation of naloxone, known as the Samaritan Law. This law gave legal immunity to people who had drug in their possession and were having an overdose from controlled substances, also to the people who had possession of said drugs but were looking for help for an overdosing patient are also granted immunity. The law also provided a naloxone prescription to anybody who would be at risk of overdosing or witnessing an overdose, therefore being capable of saving themselves or others.

                                                                                                                               

Washington State is a very good example for the federal government to use as a model to respond the epidemic. Kolodny and Frieden (2017) made ten recommendations in which can and should be used as guidelines for federal and state level, since the only way to make front to the epidemic is to fight it all at once:

1. Improve surveillance of possible opioid addiction

2. Improve reporting of and response to opioid related overdoses and fatalities.

3. Promote more cautious prescribing for acute pain.

4. Change labeling for chronic pain and greatly restrict or eliminate marketing of opioids for this indication.

5. Increase insurance coverage of and access to nonopioid and nonpharmacological management of pain.

6. Interrupt the supply of heroin and illicitly produces synthetic opioids and improve coordination between legal and public health authorities.

7. Identify possible opioid addiction early and link individuals to treatment.

8. Expand low-threshold access to opioid agonist treatment, particularly with methadone and buprenorphine.

9. Implement harm reduction measures for current users, including access to clean syringes.

10. Consider removing ultra-high dosage unit opioid analgesics from the market.

As shown with Washington State, a key factor in the success of overcoming the epidemic is the effective communication between departments, councils and every person affected by the illness one way or another. There have been some states which declared emergency status, so, they could access some benefits that gives this status such as the facilitation of strategies to face the public health crisis. This can be the easier access for rural communities to medical personnel where the opioid-related deaths are higher per capita than those in urban areas.

Inside the effective communications can be stored some law changes in which normalizes and equilibrates the way that society faces said epidemic. Some new laws can change the barriers imposed by older laws in order to have a better outcome while facing the epidemic, like the ones that Washington State approved. Of course, there has to be taken in consideration factors of risks and possible outcomes for these laws and measure if the benefits are better than the liabilities.

        Another way to face the epidemic is to check and improve the emergency response towards cases involving opioids through laws. The patient-prescriber surveillance, a reduced medical prescribing and the immediate availability of council for addicts are some ways in which lawmakers can diminish the actual addiction and prevent future people to suffer the illness. Other ways are the effective prosecution of drug dealers associated with these drugs primarily, also the prosecution of unethical physicians & pharmacists. A very important agency in this matter is the United States Customs and Border Protection (USCBP), who should be blocking entries of illegal opioids and tracking down the ways of entry of these types of drugs. It is not a secret that one main manufacturer is in China. Now, how do USCBP keep up with them in order to intercept the drug traffic is one big question with short possible answers.

The USCBP is not the only agency that has to make an effort, the Food and Drug Administration (FDA) and the National Institute of Health (NIH) are also agencies in which a big responsibility falls upon in order to combat the epidemic. Both of these agencies have on-going researches as the science field helps to look for short and long term solutions. Some of these projects are new formulations of exciting medications to bypass the limiting barriers that exist in present time. Making more accessible drugs such as better and longer lasting mu and kappa antagonists; developments of vaccines and manipulated formulations in order to make more difficult the illicit administration through snorting or injecting are some of the short term solutions that are evaluated towards the fighting of the epidemic. Nonetheless, long term solutions are focused in the development of new generation of non-addictive yet powerful opioids. Also in finding alternatives solutions to treat chronic pain such as treating pain with a mixture of morphine and an antagonist for the type 3 dopamine receptor or treating pain via the endocannabinoid system.

        Another important aspect in how the government should respond in through the facilitation of education of this matter. The Center of Disease Control and Prevention (CDC) highlight the importance of physician and pharmacist education for this matter. These two figures are the first front since from them are the prescriptions taken and dispatched. Also educational consultations to people already ill helps them cope and understand what is going on through them. Keeping in mind illnesses associated with opioids, such as hepatitis C, and educating about them is also helpful since it keeps society at a constant reality check. Special classes, lectures and programs help society in general to understand the huge impact that it has in an ill person’s life.

        The government has a lot of issues at hand, internally and externally. It is the control point for society to run its course. Maybe it's time to take the lead as a society and let the government follow and give the helping hand when needed. The only way to overcome this epidemic is when everybody works together without questioning.

References:
Franklin, G., Sabel, J., Jones, C. M., Mai, J., Baumgartner, C., Banta-Green, C. J.,Tauben, D. J., et.al. (2015). A Comprehensive Approach to Address the Prescription Opioid Epidemic in Washington State: Milestones and Lessons Learned. American Journal of Public Health, 105(3), 463-469. doi:10.2105/ajph.2014.302367
Gostin, L. O., Hodge, J. G., & Noe, S. A. (2017). Reframing the Opioid Epidemic as a National Emergency. Jama,318(16), 1539. doi:10.1001/jama.2017.13358
Kolodny, A., & Frieden, T. R. (2017). Ten Steps the Federal Government Should Take Now to Reverse the Opioid Addiction Epidemic. Jama,318(16), 1537. doi:10.1001/jama.2017.14567
Madras, B. K. (2017). The Surge of Opioid Use, Addiction, and Overdoses:Responsibility and Response of the US Health Care System. JAMA Psychiatry,74(5), 441. doi:10.1001/jamapsychiatry.2017.0163
Murthy, V. H. (2016). Ending the Opioid Epidemic — A Call to Action. New England Journal of Medicine, 375(25), 2413-2415. doi:10.1056/nejmp1612578
Volkow, N. D., & Collins, F. S. (2017). The Role of Science in Addressing the Opioid Crisis.New England Journal of Medicine,377(4), 391-394. doi:10.1056