May 2019, Volume XXXIiI, No 2
Behavioral Health
Opioid prescribing
A new provider toolkit
very day, an average of 130 Americans die of an opioid overdose, according to the Centers for Disease Control and Prevention (CDC). In 2017, 401 Minnesotans died from opioid-related causes, according to preliminary data from the Minnesota Department of Health (MDH). That’s an 18 percent increase over 2015. So it’s no surprise that state admissions data also show a rise in heroin and opioid addiction across the state. The link between the opioid epidemic and heroin use is clear: 80 percent of people who use heroin initially used prescription opioids, according to the National Institutes of Health (NIH).
These numbers reflect a statistical focus on chronic opioid use or addiction. Minnesota health plans and the Minnesota Department of Human Services (DHS) are now taking a different approach. Instead of focusing on supporting or tapering chronic opioid use, this collaborative effort seeks to reduce the likelihood that opioid-naïve patients enrolled in Medicaid will become chronic users. The opportunity is significant: DHS data show that in 2012–2016, an average of 5.8 percent of Medicaid members in Minnesota who received a new opioid prescription became chronic users.
The data also show that opioid-naïve patients who used an opioid for 45 or more days following a new prescription were more likely to become chronic opioid users.
Partnering to prevent misuse
The health plans involved with this project are Blue Plus, HealthPartners, Hennepin Health, Medica, PrimeWest Health, South Country Health Alliance, and UCare. Amy Burt, DO, associate medical director for UCare, believes partnership is important, since “the collaborative includes multiple stakeholders in order to mitigate unintended consequences that could negatively impact patients and providers.”
The first deliverable of the project is a Provider Toolkit: Meeting the Challenges of Opioids and Pain (www.tinyurl.com/mp-opioid-toolkit), which consolidates evidence-based recommendations and resources into one easy-to-use resource. The tools are relevant to Minnesota and specifically address up-front issues related to working with patients to manage pain, along with tools to support clinicians. Examples include:
- Opioid prescribing guidelines
- Utilizing shared decision making with patients
- Screening for risk factors
- Alternative therapies to treat chronic pain
The toolkit also highlights considerations for special populations such as adolescents, young adults, and the elderly. Related webinars have been conducted, with more online sessions planned. Learn more at www.stratishealth.org/pip/opioids.html.
Eighty percent of people who use heroin initially used prescription opioids.
Guidelines: 3–7 days for new prescriptions
The Minnesota Opioid Prescribing Guidelines, released by DHS in 2018, break the phases of pain into three stages: acute, post-acute, and chronic. By focusing on appropriate prescribing and pain monitoring during the timeframe right after injury or surgery (acute and post-acute), clinicians can support their patients through their recovery, reduce the risk of their patients becoming chronic users of opioids, and limit the amount of unused opioids that may be used by someone else.
While policy makers look at implementing oversight—or on funding programs to impact this issue—clinicians struggle to balance patient needs with emerging evidence on opioid safety and efficacy. Dr. Burt points out that “many patients receive their first opioid prescription from specialists who are appropriately treating acute pain following an accident, injury or planned procedure. Specialists are implementing processes to limit opioid prescriptions to less than seven days. The medical community must closely monitor the impact this limit may have on primary care and urgent care providers.”
While the guidelines are not intended to take treatment control away from physicians, they do recognize that there has been wide variation in how opioids are prescribed across Minnesota, says Melissa Kizilos, MD, medical director at Blue Cross Blue Shield of Minnesota.
Adopting the prescribing guidelines into clinical practice is one way to ensure that you are not over-prescribing opioids. Most published guidance around opioid prescribing, including the Minnesota Opioid Prescribing Guidelines and those issued by the CDC and ICSI, recommend no more than 3–7 days of opioids for a new prescription. Minnesota health plans have implemented prescription limits to align with the prescribing recommendations. To eliminate confusion about the amount of opioids that can be dispensed, consider changing the default opioid limit in your electronic medical record to a 7-day supply. If you prescribe for a longer duration and the amount dispensed is reduced at the pharmacy, your patient may be confused when their prescription is changed.
Unused medication increases risk of misuse
To avoid repeat refills or after-hour requests, some clinicians prefer to offer prescriptions to cover longer periods. A Mayo Clinic study presented to the 2018 annual meeting of the American Surgical Association showed that nearly one-third of their patients didn’t use any of the prescribed opioids after surgery, and over 60 percent of the total pills went unused. However, only 8 percent of patients properly disposed of the remaining medication, resulting in a lot of unused medication at risk of improper use or diversion. A Johns Hopkins study shared at the 2017 annual meeting of the American Pain Society also showed that patients were not given information on how to safely store or dispose of leftover medications.
Prescribers can play an important role in reducing the amount of unused opioids available for diversion. Prescribing the lowest therapeutic dose needed is one part; educating patients on safe storage and disposal is also important. While the vast majority of opioid users do not go on to use illicit drugs, NIH data estimates that 86 percent of injection drug users got prescription opioids from their family or friends.
There are disposal kiosks at many Minnesota pharmacies, and the state Attorney General’s Office promotes the Dose of Reality program, which helps people find nearby disposal locations.
Shared decision making
Managing patient expectations can make the entire process work better for both the patient and the provider. Health care providers integrate shared decision making in large and small ways in almost every patient encounter. When prescribing opioids for the first time, a clear, honest discussion needs to happen to help patients understand the risks and benefits of the medications you are suggesting. Be clear that the prescription is for an opioid—patients may be aware of opioid risks, but may not be familiar with the name of a given medication.
Some patients may expect medications to completely eliminate any pain as they recover from an injury or surgery, but it is important for them to understand that pain is a normal part of healing and can even be the best indicator of their recovery. Make sure patients are aware of what their pain expectations should be.
Adults with mental health conditions receive over 50 percent of opioid prescriptions.
Resources to manage patient expectations
All treatment options should be laid out for the patient, from non-opioid pharmacological options to other therapies that may not involve medications. The risks and benefits of all options should be understood. And an honest discussion of limits is important—clarify whether the patient can expect refills, and you will make future discussions much easier. The toolkit offers additional resources to support these discussions, such as patient education and a sample opioid/pain management agreement.
Tools to screen for risk factors
In addition to discussing the patient’s physical pain, it is important to assess their risk for mental health issues and addiction. A study by Matthew Davis, published in the July-August 2017 edition of the Journal of the Board of Family Medicine, showed that adults with mental health conditions receive over 50 percent of opioid prescriptions, and use opioids at a much higher rate than the general population.
People dealing with depression or other mental health issues may self-medicate with drugs or alcohol, and people in pain may also experience depression. While a formal assessment tool may not be necessary for all new prescriptions for acute pain, clinicians should always screen for the patient’s history of substance use disorder, mental health issues, and depression. Anxiety and depression can also warp pain perceptions. The Opioid Toolkit offers suggestions on strategies and screening tools for clinicians, including the ICSI mnemonic to aid in the evaluation of risk factors—ABCDPQRS:
- Alcohol use
- Benzodiazepines and other drug use
- Clearance and metabolism of the drug
- Delirium, dementia, and falls risk
- Psychiatric comorbidities
- Query the Prescription Monitoring Program
- Respiratory insufficiency and sleep apnea
- Safe driving, work, storage, and disposal
Determining whether a patient is on the Restricted Recipient Program
Like most states, Minnesota has a Prescription Monitoring Program (PMP) to assist prescribers in safely managing their patients. While all Minnesota prescribers are required to register for the program, they are not required to check it, so some patients may slip through the cracks. Because the PMP cannot be easily accessed through most medical records, its use has been limited, but it is important to ensure that at-risk patients are not receiving medications from other sources.
In addition, Minnesota has a Restricted Recipient Program for recipients of Minnesota Health Care programs (Medicaid) who are suspected of misusing services. Patients may be limited to one medical provider and/or one pharmacy for their care. Clinicians can consult the MN-ITS Program to determine if a patient is on this program.
Alternative therapies to address the multiple causes of chronic pain
Many patients prefer to try non-opioid treatments for pain before supplementing with medication, or in conjunction with painkillers. For others, alternative therapies used in conjunction with traditional medical treatments create a more effective program to help cope more successfully with their pain. Effective alternative therapies include various cognitive behavior therapies, traditional rehabilitation therapies (physical therapy, transcutaneous electrical nerve stimulation, exercise, massage, and even simple hot/cold treatments), as well as complementary or integrative medicine such as acupuncture, tai chi, yoga, or meditation. Clinicians should educate themselves about potential alternatives and discuss the patient’s preferences using a patient-centered approach.
Alternative therapies may be covered by a patient’s insurance but often are not, so it is important for them to contact their plan member services to verify coverage. To assist clinicians in determining what alternative therapies may be covered by Medicaid, the project has created a Minnesota Medicaid Benefits Coverage Grid, located on the project page and updated annually on the Stratis Health website at www.stratishealth.org/pip/opioids.html. There are resources in the Opioid Toolkit for physicians to educate themselves about alternative therapies, as well as resources to share with patients.
Health plans are also taking varied approaches with their networks and members. Some are involved with ICSI’s MN Health Collaborative. Other plans are doing direct outreach and education to individual members or monitoring prescription rates among their network providers. Look for additional webinars on the Stratis webpage addressing these and other topics, such as the impact on rural communities and the elderly.
Summing up
Balancing the desire of patients to minimize discomfort with the need to manage medications and utilize best practice makes pain management a complicated task for clinicians. Utilizing collaborative skills to educate patients and developing recommendations to help them make the best decisions are key to successful outcomes. Screening for risk factors prior to prescribing, and educating about proper disposal, make safety a priority.
We have already seen improvements in prescribing practices in Minnesota. From 2016–2017, DHS noted a reduction of approximately 10 percent in opioid prescriptions. This issue reaches into virtually every medical setting in the state. By working together and following common sense practices, we will see this trend continue, resulting in safer health care.
Andrew R. Zinkel, MD, MBA, FACEP, FAAEM, is an associate medical director of quality at HealthPartners health plan and a practicing ER physician at Regions Hospital.
Patty Graham, is a senior quality consultant at HealthPartners.
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