Keeping Patients Safe While Treating Pain

Keeping Patients Safe While Treating Pain
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Doctors are encouraging safer opioid prescribing with CDC’s Opioid Prescribing Guideline

Throughout my many years of caring for patients, I have done my best to balance their overall well-being and their needs when treating them for pain. Ensuring safe and appropriate pain management can be a challenge - so it is important to engage patients in all decisions around their treatment.

There are many factors to consider when writing a prescription for pain medication, particularly one for an opioid. Here are some of the questions I ask myself:

  • Is this treatment option effective for the patient’s condition?
  • Does my patient know the risks and benefits?
  • What are the unintended consequences - such as addicition - that could harm the patient?

Data from high-quality studies show there are serious risks of addiction and overdose with opioids, but we also have a responsibiilty to treat our patients’ pain to the best of our abilities.

Doctors can adopt many safer prescribing practices, while doing everything they can to make sure their patients have the best possible pain care. I want to share two experiences from Dr. Kelly Pfeifer and Dr. Joseph Hsu, who are two professionals who are champions in their field, making patient safety a top priority within their organizations, health care systems, and communities and have shared information on how they are developing safer opioid prescribing initiatives.

What is working to improve opioid prescribing practices?

  • Dr. Kelly Pfeifer, Director of High-Value Care: The California Health Care Foundation (CHCF) is supporting local coalitions of both medical and community leaders to implement the CDC Guideline in diverse practices, so we can address the epidemic upstream, preventing future opioid addictiion and overdose deaths. We find what works and help spread it across the state to various collaborators through local coalitions and our partners. It takes many people and organizations to come together to change how physicians prescribe. Opioids are certainly valuable, but we need to use them for fewer conditions, at lower doses, and for shorter durations. This takes a culture shift.
  • Dr. Joseph Hsu, Orthopedic Surgeon: In the Carolinas HealthCare System, we have created a tool within our electronic medical records (EMR) that helps identify risk factors during a patient visit, before a prescription is written. This system was designed to help physicians be instantly aware of the importance of opioid misuse prevention and their role in identifying patients who are at the most risk.

What strategies work best for raising awareness about safe opioid prescribing?

  • Dr. Pfeifer: At CHCF, we have published resources on safer opioid prescribing, complementary pain therapies, and Medication-Assisted Treatment (MAT). We are also helping community health centers start addiction treatment programs and services for complex patients. Ultimately, we think we need both a top-down (state policy and public health leadership) and a bottom-up (local leadership) approach if we are going to make change stick and last. Currently, more than 35 counties in California have an active opioid safety coalition, with our state public health and health services departments providing guidance and support.
  • Dr. Hsu: We developed a decision-making tool for doctors in our EMR, and we were able to preview and promote the tool through various meetings and events. We were able to create champions for this system to increase its acceptance and use throughout our hospital. Most of the doctors and prescribers were grateful to have this system in place, especially since it was integrated into an EMR system they were familiar with. They are able to use this tool to reinforce their decisions on prescribing opioids with their patients in real time, and to clearly explain the risks of inappropriate opioid use.

How has CDC’s Guideline helped to improve prescribing practices?

  • Dr. Pfeifer: Working on this issue can seem like an uphill battle, but having CDC’s Guideline was a game-changer: people stopped arguing about the facts and started debating solutions. The Guideline helped coalitions and health systems move forward and change prescribing practices through education, data, and decision support tools. We are collecting data and seeing prescribing rates decline across our state — even more so in counties with active opioid safety coalitions.
  • Dr. Hsu: CDC’s Guideline has helped bring our organization together to enusre that change was happening from the ground up. The Guideline has helped our prescribers become more comfortable having the necessary, productive conversations about opioids with their patients. It has also helped them identify patients who are most in need of supportive services, giving them the abiilty to refer them to the right specialist.

What else do physicians need to treat patients in pain?

  • Dr. Pfeifer: Some prescribers fall into an all-or-nothing trap. Some may continue unsafe prescribing — perhaps lacking the skills to taper their patients to safer opioid doses or to use alternatives. Others may stop prescribing opioids altogether, leaving “opioid refugees” in their wake. These patients are dependent on high-dose opioids and have no one to help or treat them. Neither of these is the right answer. We need to make sure that physicians have the support and training they need to implement the Guideline into their practice. Things like tapering, informed consent, using opioid alternatives, and treating addiction can feel like a lot of work at first, but they will improve patient outcomes and clinician satisfaction.
  • Dr. Hsu: We have to understand that the Guideline is not an end-point, and that this process is going to be a long journey. We need to make sure that we are moving away from opioids as the only source of pain management, and work together with our patients to develop their pain management plans. Physicians should be able to clearly explain the risk of misuse and overdose, while teaching patients about other treatments like cognitive behavioral therapy, mindfulness, and other alternative treatments.

The latest Vital Signs report shows that opioid prescribing declined betweeen 2010 and 2015 but remains at high levels (still three times higher than in Europe) and varies up to six-fold from county to county in the U.S. This variation highlights the need for all prescribing health care providers to follow best practices when prescribing opioids. Since an estimated 2 million people are currently addicted to prescription opioids, CDC is focused on targeting our prevention efforts so that we prevent more people from becoming addicted in the first place and/or overdosing.

Thanks to Drs. Pfeifer and Hsu for sharing what they do to combat opioid misuse in their communities. I am fortunate to work with so many great prescribing professionals who take such care in ensuring the safe and effective treatment of their patients. We need to make sure all health care professionals have the knowledge, support, training, and tools they need to make treatment decisions that put their patient’s health and safety first.

For more information on training for physicians on the CDC Guideline for Prescribing Opioids for Chronic Pain, please visit CDC’s Online Training for Providers.

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