Cover: Where Does it Hurt? Curbing Abuse and Preserving Patient Care

Friday, March 01, 2013 12:00 PM

By Kate Alfano, CMS contributing writer

A January 2013 report revealed a disturbing statistic: Colorado has the second-highest rate of non-medical prescription drug abuse in the nation. The National Survey on Drug Use and Health by the Substance Abuse and Mental Health Services Administration shows that 6 percent of Coloradans ages 12 and older report having abused prescription pain relievers in the past year compared to a national average of 4.57 percent. The highest rate of abuse occurs in the young adult population; 14 percent of Coloradans between the ages of 18 and 25 reported misuse of the drugs in 2010-2011 compared to 10.43 percent nationally.

As prescribers of these medications, physicians play a central role in this issue. This is why, far before the study’s publication, the Colorado Medical Society began to study the relationship between pain management, prescribing practices and patient safety.

Most recently, the CMS board of directors voted at their Jan. 18 meeting to make the issue of prescription drug abuse a high priority and directed the society to work proactively with the governor, his staff and appropriate state agencies and stakeholders on effective strategies to reduce prescription drug abuse in Colorado.

Though several agencies within state government have taken on this issue and the Colorado Prescription Drug Abuse Taskforce has been active for many years, Colorado’s efforts gained national attention when the National Governors Association selected Colorado Gov. John Hickenlooper as the co-chair of a national prescription drug abuse project that brings together senior-level policymakers in seven states – Colorado,
Alabama, Arkansas, Kentucky, New Mexico, Oregon and Virginia – to develop and implement both comprehensive and coordinated strategies that leverage available tools and resources to address prescription drug abuse.

They will examine building a prescription drug monitoring program coordinated between states and within regions, assess regulatory and legislative barriers, examine best practices, coordinate education, and guide proper medication disposal and enforcement. Participating states are scheduled to release a report by the end of February.

Kelly Perez, human services policy advisor for Gov. Hickenlooper, says that the public perceives these medications as safe because they’re prescribed by doctors but that we – physicians and the state – need to educate the public on the dangers of these substances when not used properly.

“Doctors have a role in advising state efforts, creating policies and adopting safe prescribing,” Perez says. “You’re the ones who will know the best medical education opportunities and how to make them available for physicians. We’ll work on usefulness of resources and safe disposal, and how to develop uniform messaging so we aren’t giving different messages to the public.”

Naming Colorado’s Prescription Drug Monitoring Program database, the Colorado Medication Take-Back Pilot Project and efforts by the attorney general and others, she says that the state has all of the pieces we need to move forward. “I think it’s our responsibility to unify these projects and to come up with a state plan.”

Leading CMS’ effort is the CMS Workers Compensation and Personal Injury Committee, or WCPIC. CMS President Jan Kief, MD, named 12 special advisers to the committee who have demonstrated expertise on the subject, and these advisers will also work with the governor’s office to provide insight and feedback on policies. Chaired by occupational medicine physician John Hughes, MD, WCPIC held its first meeting on prescription drug abuse on Jan. 17.

Dr. Hughes says WCPIC will focus on three points initially, beginning by endorsing the Colorado Medication Take-Back Pilot Project, coordinated by the Colorado Department of Public Health and Environment, and encouraging its expansion. Since its launch in December 2009, the program has collected more than 25,000 pounds of medications and has increased awareness of the environmental and public health concerns related to improper medication disposal with overwhelming public approval. But Greg Fabisiak, CDPHE environmental integration coordinator, says, “identification of sustainable funding sources is the greatest challenge facing existing programs and efforts to expand them.”

Second, WCPIC will focus on the dilemma faced by physicians who treat patients for chronic pain and who must change a patient’s medication midway through the previous prescription. “They have to do some sort of take-back to reacquire custody of the unused medication,” Dr. Hughes says. “Currently this is a problem. There needs to be some rulemaking that protects physicians who do chronic pain management and allows us to take back medications.”

“The third takeaway point is that we need to increase physician education regarding using the Prescription Drug Monitoring Program database. We need to refine guidelines that are already developed under the supervision of the Colorado Division of Workers’
Compensation pertaining to controlled substances. Their narrow application to workers’ compensation doesn’t help most Colorado physicians, so we need to broaden those guidelines and make them more available to educate physicians, promulgating guidelines for when physicians should query the PDMP.”

“One of the reasons that providers need to be in the forefront is because it’s the providers who were pushed to give all these pain medications to begin with based on things that happened 10 years ago,” says Kathryn Mueller, MD. She’s a WCPIC advisor and also medical director for the Division of Workers’ Compensation and professor in the Department of Emergency Medicine and School of Public Health at the University of Colorado School of Medicine. “The policy for providers was that you’ll be punished if you don’t treat pain, and we need to treat pain but we need to do it properly.”

Dr. Mueller supports developing new education and building on existing education for physicians and providers managing chronic pain rather than imposing additional screenings and regulations. CMS must be the moving force, she says, because physicians will be the ones implementing new policies and using the resources. “Particularly with the PDMP, the providers have to be the ones telling us what works best for them and how they are going to use it more because right now it’s underutilized. Providers need to be the leaders because other sources don’t really understand how clinics work and how physicians practice. We’re going to be the ones doing it; we’re the ones responsible.”

The willingness for physicians to prescribe narcotic therapy with suboptimal indications is one factor of prescription drug abuse, and the solution will be “predominately a matter of physician education and having physicians understand that for nonmalignant, nonterminal patients, chronic narcotic therapy just doesn’t have great outcomes in a majority of patients,” says Ken Cohen, MD, F.A.C.P.

Dr. Cohen is a WCPIC advisor, internal medicine physician and chief medical officer for New West Physicians. Self-observation and assessment helped his Denver-area primary care group practice take action to ensure proper prescribing.

Several years ago, the group identified a provider who had been prescribing large doses of narcotics without well-described indications and came together as a group to set their future procedure.

“We encouraged narcotics to be used for short-term use only,” Dr. Cohen says. “If long-term narcotics are being used for treatments other than cancer pain or terminal illness, we require consultation with a specialist who has a direct relationship to whatever indication the narcotic is for; by that I mean, if it’s intractable back pain we consult with an orthopedic surgeon. We don’t want any of our physicians prescribing chronic narcotic therapy for nonmalignant pain in the absence of consultation.”

New West Physicians also mandates that every patient of chronic narcotic therapy have a narcotic contract. They look at the past two years of narcotic prescribing for all new physicians in the group to make sure to identify appropriate narcotic prescribing practices. Lastly, for any patient new to the group who comes in with chronic narcotic use, PDMP use is mandated to make sure that there’s only one physician prescribing narcotics.

CMS will continue to work with the state to develop appropriate policies to reverse the escalating trend of opioid abuse and its often-tragic consequences. WCPIC advisors will participate in roundtable discussions this spring hosted by CDPHE, the governor’s office and the Colorado Department of Human Services, focusing on drug disposal, physician and provider education, public awareness, the prescription drug monitoring program and epidemiology.

In a Jan. 29 letter to the governor, CMS urged consideration of strategies that significantly reduce the potential for diversion to recreational or medically inappropriate use and risk of overdose and the resulting range of medical, psychological and social consequences, while assuring compassionate, evidence-based care for patients who suffer from chronic non-cancer pain.