By Lesley Brooks, MD

The opioid epidemic is one of the greatest challenges facing health care today and physicians have a role in reducing opioid misuse and abuse in our patients. Unfortunately physicians can feel like they are cast in an unfair spotlight with this issue. Tom Frieden, MD, MPH, former director of the U.S. Centers for Disease Control and Prevention, was absolutely correct when he said this is a doctor-driven epidemic. No one else prescribes these medications but physicians, dentists, veterinarians and other licensed health care professionals.

That said, also contributing to this epidemic were our partners in the pharmaceutical industry, hospital accreditation and other advocacy organizations, and, perhaps most important, a lack of robust science about the effectiveness and consequences of chronic opioid medications – science that has evolved significantly since the early 1990s. We now know what we didn’t know before: that these medications can be and are addictive, no matter the patient population; and that these medications can be and are life-threatening if taken inappropriately.

Further, policymakers and health care experts do understand many of the challenges we face as physicians in our current health care environment. They know that it can be challenging to treat someone with multiple chronic medical conditions, many of which can cause discomfort; that it can be challenging to distinguish between the person with opioid use disorder and the person whose pain may not be well controlled; and that it can be challenging to know when the person who has been taking their legally-obtained opioids safely for months has transitioned to misusing them.

Through my practice at Sunrise Community Health, which serves both Larimer and Weld counties, my tremendous team of providers delivers full-scope family medicine including Medication-Assisted Treatment (MAT) for opioid dependence. The latter, including treatment for pregnant women, we do within a strong partnership with North Range Behavioral Health and SummitStone Health Partners. The real-world knowledge gained through our experience inside this collaborative model to ensure physicians have the tools to prescribe opioids safely can be applied throughout our region to protect our patients and increase our quality of care for those suffering from chronic pain or opioid addiction.

I want to emphasize the importance of offering MAT for pregnant women, a population who are at high risk for relapse and death without access to effective treatment and who are highly motivated to begin recovery. Withdrawal can be extremely dangerous for a fetus and MAT is safe and highly effective in this population. If this is not an area you feel comfortable with, please get in touch with someone who is (see resources at the end). At Sunrise, we are usually able to see our pregnant substance-using patients within two to three days.

Starting with the basics on opioids, it is important for physicians to understand that our patients do have legitimate and organic chronic pain conditions. They can and do develop opioid use disorder on the medications that we give them, even those who have a well-documented source for their discomfort and even those who have a history of using their medications safely. Sometimes patients present with descriptions of chronic pain that are difficult to attribute to a physical source, and that can sometimes be associated with psychiatric or behavioral disorders. It is critical to complete a good assessment to determine the appropriate treatment modality. Some pain is not likely to improve, and may worsen, with chronic opioid therapy, such as abdominal pain, headaches and neurologic pain.

Physicians have made some progress in addressing this epidemic. The latest figures from the American Medical Association show that the total number of retail-filled prescriptions for all opioid analgesics in Colorado has decreased 13.3 percent between 2013 and 2016, from 3.7 million in 2013 to 3.2 million in 2016. And use of the Prescription Drug Monitoring Program (PDMP) in Colorado has nearly tripled from 680,000 searches in 2014 to 1.5 million in 2016.

However, this does not necessarily mean that we are getting the training that we need to make better prescribing decisions. This is a huge educational gap.

Safe opioid prescribing is about understanding how to assess the patient with chronic pain, including past medical history, past treatments for pain, what worked best to improve their function and what didn’t, imaging, other chronic conditions both physical and mental, physical examination findings, etc. Safe opioid prescribing is also about making as specific a diagnosis as you are able based on the data you obtain, understanding what medications are available for the condition you feel you are treating and are appropriate for different types of pain, and then helping your patient select the safest regimen for them.

Following the steps outlined above involves strong assessment skills and strong communication skills. Helping the person who has come to seek your guidance to select the safest regimen for them may mean that opioids are not an option or that the opioids they request and the valium they are already taking are incompatible and you cannot support that regimen. I urge all physicians to obtain the training needed to help strengthen these communication skills if you haven’t already. In addition, I would strongly encourage physicians to obtain a DATA 2000 waiver that allows you to prescribe buprenorphine (ex. suboxone) so you can treat opioid use disorder if and/or when it begins. It can also be helpful for some chronic pain indications.

Further, it is important to establish the parameters within which you will prescribe opioid medications to your patients and the circumstances under which you will no longer be able to prescribe for them. We refer to this as a medication agreement. In the past, it has been referred to as a pain contract. I like the term “agreement” because it implies a mutual understanding. Again I emphasize communication skills because I don’t like the idea that there are terms under which my patient will violate their contract and thus be discharged from my practice. And we at Sunrise don’t use that language with our patients. We prefer the idea that there are parameters within which we will continue with the regimen that we have agreed upon and outside of which the terms of our agreement must change.

For example, if a patient is going to use methamphetamine while taking the oxycodone that I have prescribed, I am going to insist that he or she see our behavioral health therapist for substance use assessment (thank you North Range and SummitStone for these invaluable team members!) and attend our weekly group visits (see sidebar) while he or she works on stopping the methamphetamine. If not, we must treat the chronic pain with something other than an opioid. Our therapeutic patient-provider relationship is never at risk because of misuse. If anything, it is an opportunity to enhance it, to understand better the conditions with which our patients struggle.

I would also encourage providers to understand the policies of their local emergency departments and how they will handle patient requests for pain medicines. I would also encourage you to let them know how your practice is handling opioid prescribing and how they can refer patients back to your practice.

Finally, it is important to seek out training so that we can recognize opioid use disorder in the outpatient setting. (See DSM-V-Substance Use Disorder Diagnosis.) I emphasize this because it often looks different than what one might find in a traditional substance use treatment setting. (The illness of addiction is the same in both settings; I mean only that its presentation differs and we need to recognize that.) Unless we are working in the substance use field, we as physicians are likely unaccustomed to addressing this issue in our offices.

With someone who is illicitly using heroin or another substance, that conversation, that framework is clear (though admittedly not easy). But for someone who is obtaining the means of their addiction legally from you for what you and they believe to be a legitimate condition, the conversation that a physician needs to have when their use has become problematic is nuanced and, perhaps most important, a new skill for us. We need to understand the criteria for opioid use disorder and how to apply it.

The Colorado Consortium for Prescription Drug Abuse Prevention is a tremendous repository for state-specific information on this epidemic. They currently link to a two-hour physician CME course, “The Opioid Crisis: Guidelines and Tools for Chronic Pain Management,” from the resources tab of the top-bar navigation.

The North Colorado Health Alliance and the consortium have collaborated on the Colorado Opioid Epidemic Symposium, a series of provider education events offering CME and COPIC points. The symposium offers full-day, half-day and evening events for providers to obtain the skills highlighted in this article. The most recent evolution of the symposium is “Moving From What to How: Safe Opioid Prescribing for Chronic Pain,” a 2.5-hour evening CME program focused on educating providers and other members of the multi-disciplinary team. Providers and practices can request training by contacting Whit Oyler at whit.oyler@ucdenver.edu or Deirdre Pearson at dpearson.alliance@nocoha.org.

Additional CME can be found as part of the 2017 CMS Annual Meeting in Breckenridge Sept. 15-17, when Consortium chair Rob Valuck, PhD, will give a one-hour update Sunday morning on the opioid crisis in Colorado and the United States. All programming and social events for the conference are free for NCMS/CMS members and a guest, and child care is provided during many of the conference events.

Finally, the Region VIII Opioid Addiction Consultation Team will host the Region VIII Opioid Summit Aug. 14-15 in Denver. This is also a free, but space limited, program.

Dr. Lesley Brooks serves as the Chief Medical Officer for Sunrise Community Health, as the assistant Medical Director for the North Colorado Health Alliance, and as co-chair of the Provider Education Work Group for the Colorado Consortium for Prescription Drug Abuse Prevention.

____________________________________________________________

Sidebar: Sunrise institutes comprehensive opioid oversight and buprenorphine treatment program

Sunrise responded early to the nationwide epidemic of prescription drug abuse, especially with regard to opioids. Our medical team noted early on that there were some patients who were misusing their opioid prescriptions and that our providers needed support to prescribe opioids safely as everyone had a slightly different approach. In direct response to aberrancies in patient behavior and widely varying provider prescribing behaviors, Sunrise established the Opiate Oversight Committee (OOC) in 2008. The purpose of the committee is to establish and maintain best practices for opioid prescribing among providers, provide comprehensive review of patients receiving on-going opioid prescribing, and provide recommendations to improve safe prescribing to providers. Sunrise supported this effort by freeing three physicians to participate in the OOC, hiring an OOC case manager, and developing the relevant reporting to support this work.

The committee meets weekly to review all patients receiving on-going prescriptions for opioid pain medications and those who are identified with high-risk behaviors. As part of the review process, a written document is generated with the assessment and recommendations for the provider. The committee deliberately chose to provide recommendations to providers rather than to establish separate workflows to engage directly with patients. We felt strongly that we wanted to educate providers as a result of the review process and leave the patient-provider relationship intact, thus honoring our philosophy that chronic pain is absolutely part of the primary care relationship and should be managed within that structure unless specialty care is required.

A few years after establishing the review process, we recognized that while we had improved communication to and education of providers, there were some patients who were not receptive to these and who, despite improved safety in our prescribing, continued to exhibit unsafe behaviors. Consequently, we experienced frequent outbursts in our pharmacy and during office visits by patients who did not understand changes in their medication regimen or were confused by new policies. In part, this was our fault for not effectively communicating these changes to our patients and how they would affect them. We then evolved the OOC to include twice weekly group visits for patients who needed a higher level of care and as a way of communicating some of these messages. Throughout our community, we were experiencing the arrival of new patients who had been terminated by their previous provider for aberrancies in managing their opioid medications. While we also noticed similar aberrancies, we wanted to maintain a therapeutic relationship even in the face of potentially aberrant behaviors. Firing patients from our practice is always a last resort and we try very hard to avoid this.

The group visit is designed as a higher level of care to which we could refer patients who exhibited unsafe behaviors with these controlled substances. The visit, which involves one of our OOC providers as well as a behavioral health consultant, allows clinicians to respond to high-risk behaviors and enhances our ability to monitor these patients more closely. Group visits are an hour long and involve shared teaching around concepts such as safe mediation storage, skills for coping with chronic pain, the role of psychiatric and other chronic medical conditions in chronic pain, and alternatives to opioid medications for pain. Typically, patients are asked to attend weekly group visits for four weeks with a requirement to also have supportive urine drug screens at each group visit.

If the unsafe behavior can be corrected via group visits, the patient is returned to routine monthly follow up with their PCP. If the unsafe behavior continues despite this higher level of care, the patient is told that controlled substance prescribing must be discontinued as it is no longer safe to do so, but that we can and will continue to be their medical home and that we can and will continue to treat their chronic pain condition(s) with non-opioid medications. Any specialty services from this point forward are made with a specific request for intervention rather than management of additional opioids. Patients can be re-evaluated for re-initiation of opioid medications.

Through this enhanced mechanism for safety, we have also established training for safe opioid prescribing for all of our new providers during provider orientation.

Throughout our system, providers have appreciated OOC involvement in patient care and the enhanced education of providers delivered through systematic review of patients. Patients have also expressed increased satisfaction with the management of their opioid prescriptions and the teaching around safety and skills-building delivered through the group visits.

____________________________________________________________

Resources for treating pregnant women

• Sunrise Community Health (Weld or Larimer counties) – Contact Melynda Childers (970-350-1155) or Michele Steinmetz