What is the Opioid Epidemic?
Over the past two decades, opioid misuse in the United States has reached epidemic proportions and become a national health crisis. In 2017, the number of overdose deaths involving opioids was six times higher than in 1999. Today, opioid overdoses claim the lives of more than 130 people every day with devastating effects that touch all corners of society, from public health to social networks and economic systems.
Managing the opioid crisis presents a particular challenge for healthcare providers, who are often faced with a double-edged sword. On one hand, clinicians understand that prescribing these drugs may contribute to the addiction crisis. At the same time, opioids can give patients much-needed pain relief, especially those dealing with cancer or surgery-related pain. Given the complexities of the issue, how can healthcare providers deliver effective opioid treatment while also ensuring patients’ health and safety?
Proper clinician training and education, targeted clinical screening tools and integrated care services are some of the many effective strategies that can help you manage the opioid crisis in your medical community.
Confronting the Narrative on the Street
There’s no question that prescription pain killers like opioids often serve as a gateway to illicit drugs—roughly 80% of heroin users began misusing drugs after initially taking an opioid prescription—but that doesn’t mean all opioids should be swept from pharmacy shelves.
Kevin Jarrard, CEO of Specialty Management, Inc. a multi-site orthopedic, spine and pain-management physician group in Georgia, believes part of the challenge is countering the narrative on the street that all narcotics are bad, and that anyone who prescribes them is doing something wrong.
“We’re scrambling trying to put forth a competing narrative that emphasizes that narcotics are a tool that clinicians use to treat patients,” Jarrard says. “Physicians are under tremendous pressure to treat patients who need opioid prescriptions and also navigate complex regulatory and compliance laws.”
In 2016, the CDC issued opioid prescription guidelines for chronic pain, including recommendations for medication selection, dosage, duration, patient monitoring and reassessment. In addition, laws surrounding prescription pain management vary state by state. All of these regulations are important for protecting patients’ health and safety and should be considered in treatment decisions, Jarrard says. However, he also emphasizes that the patient-provider relationship is critical to the prescribing process, and each patient’s case should be evaluated based on his or her individual needs and the provider’s professional judgment.
Opioid Risk Screening
Providing appropriate individualized care to patients with chronic pain and/or opioid use disorders (OUDs) requires getting to the root cause of their health problem(s) and gaining a comprehensive understanding of their family and medical history, their social determinants of health and whether they exhibit tendencies toward drug misuse. Patient-reported outcomes and other clinical screenings, such as the Opioid Risk Tool (ORT), offer healthcare providers an effective way to assess a patient’s risk for opioid misuse. Specialty Management has found the ORT highly valuable for gathering critical patient data that informs their treatment.
“We use the ORT at our spine intervention office for patients with acute injuries or others dealing with the aftermath of significant trauma,” Jarrard says. Less than three months after implementing the opioid screening tool, the practice increased ORT screenings by 195% and identified an additional six high-risk patients per physician per month, he says.
If a patient identifies as having struggled with narcotic use in the past or shows addictive tendencies, providers will look for alternative ways to treat his or her pain, such as nerve-block medications, Jarrard says.
“We always try to help them understand the dangers of short-term narcotic use and ensure that they’re weaned off of them as quickly as possible,” he says. “Or, we look for more conservative alternative treatments like physical therapy, chiropractic care or anything that can provide a more complete solution.”
Addressing the Opioid Epidemic Stigma
Essential to identifying and effectively managing pain for patients with OUD is making sure they feel they are being treated as a whole person, not defined solely by their substance use disorder. Benjamin Bearnot, M.D., a primary care physician at Massachusetts General Hospital in Boston, who also works as an internist and addiction medicine specialist at a local community health center, stresses the importance of asking patients about their behaviors in ways that makes them feel safe and supported.
“The stigma of substance use disorder is such that if you ask people questions about it that are incorrect or asked in a stigmatized way, this disease remains in the shadows,” Bearnot says. Instead, providers should focus on identifying whether patients’ substance use indicates high-risk patterns or results in negative consequences.
“Substance use itself is not the problem,” he says. “It’s the negative consequences in the person’s life that define the disease. Asking patients explicitly what their goals are regarding their substance use instead of imposing on them what you think their goals should be is an important entrance into that discussion.”
Leveraging Patient Engagement
Understanding the consequences of substance use gives patients more awareness about their risks and can help them engage more fully in their care.
As the opioid crisis continues to draw mainstream media coverage and public awareness, patients are more likely to have heard about the dangers of narcotics and may have questions about their own opioid use. That concern gives healthcare providers a valuable opportunity for meaningful patient discussions.
“Patient education is at the heart of this, because providers must educate them on the benefits and risks,” Bearnot says.
Providers who decide to prescribe opioids to help their patients manage pain should discuss proper dosages and safety precautions with them as soon as that decision is made. That communication might include offering patient engagement technologies such as informational videos and other messaging during intake, as well as setting realistic goals with patients, discussing what kinds of pain they may experience during treatment or post-surgery. That conversation will better prepare patients, especially those facing surgery, to deal with their pain expectations ahead of time.
“You want to have these conversations before the operation, and talk about the whole process during the pre-surgery appointment,” Jarrard advises. “We tell [patients] that it’s extremely important to follow their drug regimen carefully so that they can manage their pain effectively.”
Building an Integrated Care Team
The opioid crisis presents a unique opportunity for healthcare providers—and not just those on the frontlines of the epidemic in the emergency department—to work collectively to combat opioid use disorder and overdoses. A comprehensive care team that brings together physicians, nurse practitioners and addiction specialists to support their fellow clinicians in prescribing fewer opioids can offer valuable expertise and resources for tackling pain management from multiple angles.
Bearnot says building an integrated primary care team allows practices to broaden treatment options for patients with OUD and provides additional staff resources and support. “I think that team-based care and the patient-centered medical home model dovetails nicely with how we should be delivering addiction care,” he adds.
Integrating primary and pain management care as well as coordinating with behavioral health and wellness experts also can help healthcare organizations reduce costs, increase patient satisfaction and most importantly, improve the overall health and quality of life for those struggling with opioid use disorders.