A recent nudge from HHS to encourage naloxone for patients on long-term opioids and at high risk is helpful. While naloxone can be helpful in treating opioid overdose, HHS and other agencies now need to recognize that preventing catastrophic overdose events will require even greater care than most insurers or regulators have shown to date. Current CDC data reveal that the number of opioid overdose events involving typically prescribed opioids (and no heroin or fentanyl) remains constant at between 8,500 to 10,000 patients a year, despite opioid prescribing per capita being 19% lower than it was in 2006. Since we have not reduced the type of overdose that most involves patients treated for pain who receive opioids, we need to reexamine the evidence on how best to protect this important population.
The research on how opioid-receiving patients wind up dead shows us that it's not just getting too high a prescribed dose that explains this tragedy, even if dose matters. Instead, in patients receiving prescriptions, the events we call overdose typically involve a combination of prescribed and non-prescribed substances, along with emotional distress and medical problems, leading to chaos. What does that mean for health care?
The best protection for patients who receive long-term opioids involves getting them into care relationships where the health questions and the medications can be managed comprehensively. The worst risk to patients who receive long-term opioids is what many policies from insurers and government agencies now entail: threatening or warning doctors who have patients on opioids and telling them they are at risk based on the number of patients at a given dose. Sadly, the latter initiatives are increasingly popular among health care quality arbiters, state authorities, and even the U.S. Department of Justice. The effect of these policies is to push doctors to abandon their patients with pain, as those patients inevitably come to feel like liabilities.
Right now, a lot of doctors are operating out of fear. A lot of my colleagues cut opioids for long-term pain patients in order to rid themselves of a liability. As long as regulators and payers incentivize care in this way, patients cannot be optimally protected, and many will be harmed.
Hospitals, health systems and/or insurers could do far better. They should set up multidisciplinary teams to provide guidance to doctors who are worried about their long-term pain patients who receive opioids. Those teams can review the records, provide safety tips, and help the clinician identify rehabilitation resources and make cautious decisions regarding opioids. Those decisions need to be individualized for the patient's situation. Patients who have long-term pain and complex opioid challenges may need case management and review to stop them from being abandoned.
Similarly, HHS should have CMS encourage clinicians to coordinate care for complex patients with long-term pain. CMS and others should promote outcomes measures that track what is actually happening to pain patients, rather than just tracking their prescriptions. That includes checking whether patients live or die after opioids are increased, decreased or stopped.
Recent reports from an HHS Task Force and a CDC advisory group expressed similar concerns. Both recognized that pain care should be sensitive to individual needs. Both highlighted ongoing risks from narrowly construing opioid dose, and dose alone, as the definition of whether care is good or bad.
Stefan Kertesz, MD, MSc
Primary care physician, professor of preventive medicine at the University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center
Disclosures: Kertesz reports receiving federal grants to support research projects and previously holding stock in Abbot and Merck. The views he wrote here are his own and do not represent positions of any federal or state agency.