Louisiana Commission on Preventing Opioid Abuse
HCR 113 Duty Assignment: Evaluate and recommend reasonable alternatives of medical treatment to mitigate the overutilization of opioid medications, including integrated mental and physical therapy health services.
Shelly Esnard PA-C
SUMMARY
Our team agrees the abuse of opioids such as heroin, morphine and prescription pain relievers is a serious problem in this country. We also recognize that the CDC analyzed recent multiple cause-of-death mortality data from the National Vital Statistics System to track current trends and shifting characteristics of drug overdose deaths. Opioids—primarily prescription pain relievers and heroin—are the main driver of overdose deaths. Louisiana did not show a significant increase in death rates and is considered a statistically insignificant state according to data from 2014. (1) However we as practitioners recognize that we still have a large abuse population in Louisiana and hope to recommend reasonable alternatives of medical treatment to mitigate the overutilization of prescriptive medications.
I. Non Opioid therapies should be "tried and optimized" before considering an opioid prescription as well as during reassessment of a patient who has received a prescription for opioids.
II. Early referral to psychotherapist by a prescriber who is not trained enough to apply good evidence based cognitive behavioral psychology.
III. Recognize physical therapy health services as one of the primary treatment paths for managing chronic pain issues.
IV. Training and utilization of MATs: Clinicians have three types of medication-assisted therapies (MATs) for treating patients with opioid addiction.
V. Ensure providers are educated regarding utilization of the Prescription Monitoring Program data and how to recognize and report potential and actual misuse, abuse, and addiction.
Non Opioid therapies should be "tried and optimized" before considering an opioid prescription as well as during reassessment of a patient who has received a prescription for opioids. (2)
The CDC ‘s Guideline for Prescribing Opioids for Chronic Pain is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain. The Guideline is not intended for patients who are in active cancer treatment, palliative care or end of life care. The CDC also released a checklist for prescribing opioids for chronic pain. (3)
· Opioids are not first-line or routine therapy for chronic pain
· Establish and measure goals for pain and function
· Discuss benefits and risks of availability of non-opioid therapies with patient
Early referral to psychotherapist by a prescriber who is not trained enough to apply good evidence based cognitive behavioral psychology.
A large percentage of these chronic pain patients have significant underlying emotional and pathological thought processes contributing to their pain. We recommend a prescriber who is not trained enough to apply good evidence based cognitive behavioral psychology to get to know a good psychotherapist in their area who specializes in pain management and establish a relationship as a good referral source. Prescribers need to ensure patients receive appropriate psychosocial support. During the tapering “off” of an opioid the practitioner needs to look for anxiety, depression and other opioid use disorders signs and offer the referral as necessary.
Recognize physical therapy health services as one of the primary treatment paths for managing chronic pain issues.
With overuse of opioids for the treatment of chronic pain becoming a national public health epidemic, the Centers for Disease Control and Prevention (CDC) released guidelines that recommend nondrug approaches such as physical therapy health services over long-term or high-dosage use of addictive prescription painkillers.
"Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain," the guidelines state ("CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016" - March 15, 2016). "Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate."
While there are certain conditions - including cancer treatment, palliative care, and end-of-life care - where opioid prescription for chronic pain may be appropriate, the CDC cited numerous cases where opioid use could be significantly reduced or avoided altogether.
"The contextual evidence review found that many non-pharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, psychological therapies such as CBT (cognitive behavioral therapy), and certain interventional procedures can ameliorate chronic pain," the guidelines state. "There is high-quality evidence that exercise therapy (a prominent modality in physical therapy) for hip or knee osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2-6 months. Previous guidelines have strongly recommended aerobic, aquatic, and/or resistance exercises for patients with osteoarthritis of the knee or hip. Exercise therapy also can help reduce pain and improve function in low back pain and can improve global well-being and physical function in fibromyalgia." (10)(11)
Additionally, the Journal of Alternative and Complementary Medicine compared outcomes for patients with chronic low back pain who were randomized to chiropractic management or pain clinic management. This study suggest that chiropractic management can yield some benefit to patients suffering with chronic low back pain with apparent biomechanical component (9).
Training and utilization of MATs: Clinicians have three types of medication-assisted therapies (MATs) for treating patients with opioid addiction.
According to the New England Journal of Medicine (4), clinicians have three types of medication-assisted therapies (MATs) for treating patients with opioid addiction: methadone, buprenorphine, and naltrexone. Yet these medications are markedly underutilized. Of the 2.5 million Americans 12 years of age or older who abused or were dependent on opioids in 2012 (according to the National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration [SAMHSA]), fewer than 1 million received MAT. Consequently, expanding access to addiction-treatment services is an essential component of a comprehensive response. Like other chronic diseases such as diabetes and hypertension, addiction is generally refractory to cure, but effective treatment and functional recovery are possible.
Ensure providers are educated regarding utilization of the Prescription Monitoring Program data and how to recognize and report potential and actual misuse, abuse, and addiction.
We need to encourage prescribers to access the Prescription Monitoring Program data. This is the best way to monitor patient’s prescriptions and prevent patients from doctor-shopping and pharmacy-shopping. According to the Johns Hopkins Bloomberg School of Public Health The Prescription Opioid Epidemic: an Evidence-Based Approach (8), PDMPs are under utilized by prescribers. Physicians identify a number of barriers with its use, including retrieval of information is too time consuming and difficult. Additionally if a Louisiana prescriber applies with pharmacy board to access the PDMP yet fails to complete all medication checks, will he/she be liable? This is a deterrent. Yet many studies show those states where prescribers are more active with the PDMP have a decrease in opioid prescribing, doctor shopping and prescription overdose hospitalizations. The American College of Physicians (ACP) supports prescribers and dispensers should check PDMPs in their own and neighboring states (as permitted) prior to writing and filling prescriptions for medications containing controlled substances. All PDMPs should maintain strong protections to assure confidentiality and privacy. (7)
CONCLUSION
We favor a balanced approach to permit reasonable alternatives of medical treatment to mitigate the overutilization of opioid medications, including integrated mental and physical therapy health services. However, prescriber education, treatment guidelines and patient documentation requirements should not impose excessive administrative burdens on prescribers or dispensers. (6) “The American Medical Association (AMA) has opposed mandatory physician education on pain management and opioid abuse in the past, although the organization recognizes the need to improve training on the subject and is engaging with the FDA on the latest proposal. Dr. Patrice Harris, chair-elect of the AMA and chair of its Task Force to Reduce Opioid Abuse, said, "We support a voluntary approach to physician education and training, with the profession being responsible for articulating the standards and what is best for specific specialties and patient populations - rather than a one-size-fits-all response." (5)
1. http://www.cdc.gov/drugoverdose/data/statedeaths.html
2. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
3. https://stacks.cdc.gov/view/cdc/38025
4. http://www.nejm.org/doi/full/10.1056/NEJMp1402780
5. http://wjla.com/news/nation-world/physicians-warn-mandatory-opioid-prescription-training-could-have-unintended-effects
6. http://annals.org/aim/article/1788221/prescription-drug-abuse-executive-summary-policy-position-paper-from-american
7. http://annals.org/aim/article/1788221/prescription-drug-abuse-executive-summary-policy-position-paper-from-american
8. http://www.jhsph.edu/research/centers-and-institutes/center-for-drug-safety-and-effectiveness/opioid-epidemic-town-hall-2015/2015-prescription-opioid-epidemic-report.pdf
9. The Journal of Alternative and Complementary Medicine, Vol 14, No 5, 2008 pp. 465-473
10. http://www.ncbi.nlm.nih.gov/pubmed/25569281
11. http://www.ncbi.nlm.nih.gov/pubmed/24756895