Panel 3: Health System Approaches to Opioid Prescribing

How to Improve Health System Approaches to Prescribing Opioids

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“I’m optimistic that many of us have learned how to be better clinicians and how to practice patient-centered care through this horrible problem.”

– Englesbe

Michael Englesbe, MD, FACS, led off the panel on health system approaches to opioid prescribing, describing how his experiences as a transplant surgeon – witnessing a sharp rise in organ donors in recent years, primarily due to increased numbers of opioid overdoses – revealed to him the true severity of the opioid overdose problem.

“Why don’t we focus on keeping people healthy as acute providers?” he asked, noting the role of dentists, surgeons and others in working toward more appropriate opioid prescribing. “Leftover pills fuel the epidemic,” posing risks for both dependence and diversion into the community, he said.

Englesbe cited U-M research that finds that 6% of patients coming into surgery healthy and not previously exposed to opioids (called “opioid-naïve”) leave that event as new, chronic opioid users, a statistic that’s true across all surgical procedures (and worse for some, such as certain types of breast cancer, where up to 20% of opioid-naïve patients will end up dependent following surgery).

He described Michigan Medicine’s efforts within its surgical training program to reduce opioid prescribing, starting as a pilot with gallbladder removal procedures – a move which reduced opioid prescriptions by half without compromising pain management.

This led to bigger models with BCBSM, and the development of post-operative pain care and prescribing guidelines for the 70 Michigan hospitals that are part of the Michigan Surgical Quality Collaborative. Michigan OPEN has now established prescribing guidelines across 25 surgical procedures.

Englesbe noted that while surgical care opioid prescribing is “a small part of a really complicated problem,” with the average individual undergoing nine procedures over a lifetime, “surely this is fueling part of the epidemic.”

The Role of Acute Care Prescribing in the Opioid Epidemic

Daniel J. Clauw, MD, U-M professor of anesthesiology, medicine, and psychiatry and director of the U-M Chronic Pain and Fatigue Research Center, discussed the use of opioids in the treatment of chronic non-cancer-related pain. He presented a stark view of the current opioid situation, and how we got here.

Clauw completed his medical training, as he said, “in an era when it wasn’t ok to use opioids to treat chronic pain,” an approach that changed after the introduction of OxyContin in the late 1990s and its subsequent promotional marketing that downplayed the risk of addiction.

As other pharmaceutical manufacturers wanted to get in on OxyContin’s commercial success, Clauw said, a cascade of forces converged to boost the popularity and widespread use of OxyContin and other opioids: manufacturers co-opted academic thought leaders, drug distributors and pharmacies looked away as pill mills burgeoned, pharmaceutical companies increasingly funded the conferences of professional organizations, all while the FDA continued to approve even more potent opioids.

Where are we now? “Millions of chronic pain patients are on opioids, and very few are getting significant benefit,” while opioid use among those living with chronic pain significantly raises the risk of death and other health risks, Clauw stated. “These are dangerous drugs, with no evidence in this setting of chronic pain,” he said.

So, what can be done? For one, the HHS Pain Management Task Force (of which Clauw is a member), will soon release a road map of recommendations for providers to help them better manage patients with acute and chronic pain. Clauw also cited the DOD and VA models for chronic pain management as progressive in this area, including strong connections between behavioral health and primary care providers, and access to treatments like acupuncture and tai chi.

“If we manage chronic pain the way that it should be,” Clauw said, “payers will have to start reimbursing for the non-pharmacological therapies that should be the bedrock for the management of these patients.”

Clauw said he’s optimistic that the new attention the opioid epidemic has brought to the pain field will rapidly lead to changes in reimbursement and care models for pain care.

The Use of Opioids to Treat Chronic Non-Cancer Pain

Michael L. Barnett, MD, MS, an assistant professor of Health Policy and Management at the Harvard T. H. Chan School of Public Health, continued the theme with a presentation on policy challenges for patients on chronic opioid therapy.

Barnett alluded to the many anecdotes of “horror stories out there about forceful discontinuation of opioid therapy” as an outcome of restrictions on opioid prescribing. He said that while we don’t yet have robust data about the magnitude of the problem, preliminary research shows that providers are stopping chronic opioid therapy far too abruptly for the vast majority of users – many without any tapering off whatsoever – which can trigger withdrawal and agonizing pain.

For or some patients, Barnett said, discontinuation appears to be disruptive enough to prompt drastic action by family members, such as obtaining opioids for their loved ones.

Meanwhile, despite the increased rate of discontinuation, the total population on very long-term opioid therapy does not appear to be decreasing, Barnett said.

“Despite all the changes in the health care system, chronic opioid use is just as common as ever,” says Barnett, “and the challenge of how to design policy that can compassionately account for these patients is just as pressing.”

Policy Challenges for Patients on Chronic Opioid Therapy

Amy Bohnert, PhD, MHS, a U-M associate professor of psychiatry and research investigator with the VA, addressed whether opioid prescribing guidelines have improved outcomes.

She provided an overview of the CDC guideline for prescribing opioids for chronic pain, which includes recommendations on when to initiate or continue opioids for chronic pain, what to use, what to discuss with patients, and how to address harms. When it was issued in March 2016, the guideline was intended to increase the effectiveness of pain treatment, reduce risk to patients, and improve patient-provider communication.

What effect did this guideline have on prescribing behavior? While opioid prescribing (including high-dose prescribing, defined as greater than 90 morphine milligram equivalents, or MME) had already been declining before the guideline’s release, it decreased significantly faster after its publication, Bohnert stated. Since the guideline itself did not have any inherent enforcement of those policies (though some states did adapt the guideline into law), the data on its influence demonstrate that these types of guidelines can have the power to change provider behavior, even without enforcement, Bohnert said.

Where we need to turn our attention now, Bohnert said, is determining what, if anything, health systems are using in place of opioid analgesics in terms of pain, and for the treatment of opioid use disorders. “As opioid prescribing went down, is there any evidence that people actually got pain care in other ways that still addressed their pain,” particularly for chronic pain, she asked, “and if they didn’t, what was that patient satisfaction and pain management like?”

The panelists discussed a wide range of topics, beginning with still-needed policy changes to address opioids and chronic pain.

“Physicians are decreasing prescribing, and they have gotten the message,” Barnett said. “At least at the state legislative level, focusing on finding more clever ways to restrict prescribing distracts us from the challenges in addiction treatment and the huge changes we need to make in our mental health infrastructure that have not been as much a part of the policy conversation as I think they should.”

The CDC guidelines on opioid prescribing limits were “misread and misinterpreted” by many legislative bodies, Clauw said, which have unfortunately led to some “knee-jerk changes that have unintended consequences.” He agreed with Barnett that most providers on both the acute and chronic pain side have been well informed about avoiding overprescribing and are behaving accordingly, but it’s going to “take years or decades” to figure out what to do for the millions of people who are already on opioids with chronic pain.

Bohnert also talked about eliminating the prior authorization for office-based buprenorphine as a way to transition patients from opioids as soon as possible when their risk for adverse outcomes becomes clear, as well as the need to ensure sufficient coverage for other modalities of pain care – such as physical therapy and yoga – that require different types of providers.

Opioid Prescribing Guidelines for Chronic Pain: Do They Improve Outcomes?

Conference Co-Chair Chad M. Brummett, MD, an associate professor of anesthesiology at U-M and a co-director of Michigan OPEN,  moderated the panel discussion. Brummett asked about the possibility of the “pendulum swinging too far” in the direction against opioid prescribing, and how we would know if we’d arrived at that point.

On the chronic pain side, “I’m not sure it can swing too far,” Clauw said, referring to reinforcing provider attitudes about initiating new chronic pain patients on opioids only as a last-line therapy. “What more could or should we have learned from the last 20-some years than these are really dangerous drugs and they don’t work that well?”

The CDC guidelines “don’t say ‘never start opioids,’ Brummett noted, but instead “set forth a pathway, where if you’re going to start them, set goals, check in on patients, and assess risk and benefits,” he said. “Despite all the backlash we have seen” around the guidelines, “they seem to be aligned with practical, rational care,” Brummett said.

“I think it’s critical that there are population-based portals for patient-reported outcomes so we are listening to patients, and we are letting them inform us how to do best care,” Englesbe said. “We have that technology now within health services research, and I think it will help keep us moving in the right direction.”

Bohnert noted there needs to be more evidence about what kinds of chronic pain patients “are benefitting from opioids or likely to benefit from opioids based on their pain condition and other personal characteristics,” but stated she didn’t think there was much current will to fund the type of research needed to answer that question.

“Where I’ve been worrying more about the pendulum swinging too far is the unintended consequences of patients with cancer,” Bohnert said. “I don’t think we’ve figured out how to make nuanced policies that do not inadvertently discourage providers from prescribing opioids to patients where it’s completely appropriate.”

“There are a lot of medical conditions where the symptoms are entirely subjective,” including almost all psychiatric and neurologic disorders, “which are really symptom-based and symptom-driven, and for a lot of those conditions we don’t have any better objective marker that we do for chronic pain patients,” Clauw said. “It’s not clear to me why pain always gets called out in that regard.” He said the notion that many patients “fake” their pain in an attempt to seek treatment introduces “an inherent distrust that you can’t believe what the patient is telling you,” which is a bias that should be removed from the way providers are trained, he said.

The panelists also discussed how to provide treatment related to trauma and pain, including training more providers to deliver behavioral, non-pharmalogical interventions.

Bohnert noted that while opioid prescribing seems to be moving in the right direction, her bigger worry is how to improve the quality and access to medications for OUD. “Having only three treatments for this condition is really insufficient for having patient-centered options,” she said.

Englesbe said one of his greatest concerns is that “we have a significant workforce problem around mental health and access to care that will start with engaging our youngest trainees to want to fix these problems with society, and I don’t think we have that now.”

“It would be great if we had effective, new analgesics, but if we just use the current treatments that we have for chronic pain in the right way, we could do infinitely better than we are right now,” Clauw stated, noting that the greatest challenge is working out reimbursement for non-pharmacological and behavioral interventions.