Acute and chronic pain management: Responsible opioid prescribing

Tuesday, January 01, 2013 12:22 PM

Patricia L. VanDevander, MD, MBA

Over the past decade, prescription drug abuse has experienced a significant increase across the United States with deleterious consequences to our public’s health and safety, bringing this issue to the attention of national and state stakeholders.

According to the National Office for Drug Control and Prevention (ONDCP): “Prescription drug abuse is the nation’s fastest-growing drug problem, and the Centers for Disease Control and Prevention has classified prescription drug abuse as an epidemic.” In response to this crisis, the ONDCP in 2011 put forth the Prescription Drug Abuse Prevention Plan, which includes a strategy covering four areas: education, monitoring, proper medication disposal and enforcement.

Every provider with prescriptive authority in Colorado is encouraged to look at the evidence currently available for our state and to adopt the recommendations to avoid increased regulations on our prescribing privileges. Here are just a few of the disheartening statistics for Colorado:

1. According to Peer Assistance Services, Inc., deaths related to the most commonly abused prescription drugs nearly doubled from 228 in 2000 to 414 in 2010, while deaths related to the abuse of prescription opioids more than doubled from 180 in 2000 to 343 in 2010.
2. In 2010, more than twice as many people in Colorado died from prescription drug abuse (414) than from drunk-driving-related crashes (127).
3. A 2009 Youth at Risk survey conducted in a Denver-metro community revealed that more than 33 percent of high school students had abused prescription medication. This is significantly higher than the national data of 1 in 5 teens (20.9 percent) reporting the abuse of prescription drugs in 2009.

On a positive note, Colorado actively engaged in three of the ONDCP strategic areas prior to 2011. Our Prescription Drug Monitoring Program (PDMP), an electronic database of all Schedule 2-5 drugs dispensed by non-federal outpatient pharmacies licensed in Colorado, went live on February 4, 2008 and contains information from July 2007 to present. Helen Kaupang, diversion group supervisor for DEA, has organized in cooperation with local law enforcement three Take Back programs across Colorado since 2010. The last program in September 2012 netted 12,260 pounds of unused drugs and 244 tons nationwide. There are also several organizations within Colorado working on public education.

Taking steps to solve the problem

Colorado provider awareness and education about prescription drug abuse and its threat to public health and safety is crucial. We must be part of the solution; not a contributing factor. To address this, The Colorado Prescription Drug Abuse Task Force organized a dynamic group of Colorado physician experts to present related topics. On Nov. 15, approximately 200 providers from across Colorado attended a 3.5-hour educational program, either in person or via live webinar, titled “Acute and Chronic Pain Management: Responsible Opioid Prescribing.” This free program was held at the CU Skaggs School of Pharmacy on the Anschutz Medical Campus and made possible by generous donations from The Colorado Division of Behavioral Health, CU Skaggs School of Pharmacy and Occasions Catering. In addition to the webinar, participants received dinner, 3.5 CME credits by Colorado Medical Society and two ERS points by COPIC.

The program was led by Kelly Perez, health services advisor for Gov. Hickenlooper’s office, and Chris Urbina, MD, executive director, Colorado Department of Public Health and Environment. Both emphasized that top stakeholders in our state are aware and interested in curbing this crisis.

Ms. Perez noted that Gov. Hickenlooper has placed mental health and drug abuse on his list of “winnable” health issues and has dedicated his efforts to co-chair the National Governors Association’s yearlong initiative on prescription drug abuse. To learn more about this go to www.nga.org/cms/rx.

Dr. Urbina then put into perspective the tremendous number of prescriptions written in 2011 across the country (3.8 billion = 12.1/capita), in comparison to in Colorado (49.8 million = 9.7 per capita) and the estimation of 1.5 million prescriptions wasted each year. This translates into many of the unused drugs being disposed of in the trash (33.8 percent) or flushed (14.7 percent). One result of this epidemic has been a feminization of our fish, highlighting the fact that not only are we facing a prescription drug abuse crisis but also water contamination.

Steven Wright, MD, who divides his clinical practice into primary care, addiction medicine and medical pain management, addressed the definitions of acute and chronic pain, emphasized the necessity of appropriately treating acute pain and gave a stepwise approach to the evaluation of the patient with chronic pain. He stressed the importance of clarifying upfront the patient’s goals and function (which are documented at each visit) and then communicating a willingness to provide treatment with clear expectations, such as prescription management, informed consent for medications and urine drug testing. In addition, he spoke of non-medication treatment choices, drug selection and opioid adverse events. His approach to patients with pain was clear and compassionate.

A new software vendor was contracted for the PDMP, and a new requirement in the statute was added. Jason Hoppe, MD, a toxicologist at the Rocky Mountain Poison and Drug Center and assistant professor in the Department of Emergency Medicine at the University of Colorado School of Medicine, and Tia Johnson, PDMP administrator on the Colorado State Board of Pharmacy, gave a live demonstration on navigating the new Website and answered audience questions. Dr. Hoppe emphasized the importance for all providers with prescriptive authority to register on the site (www.coloradopdmp.org) and to access it regularly for patients whom they are considering prescribing Schedule 2-5 drugs. Currently only 18 percent of physicians licensed in Colorado are registered to use the PDMP. He also reminded everyone that the website is not real-time; therefore it may take up to 25 days to see a dispensed prescription in the system. The PDMP must be accessed only by a provider obtaining information about a patient he/she is treating, and a new part of the statute specifies that the prescriber must inform patients that their information will be entered into the database.

Kathryn Mueller, MD, medical director for the Colorado Division of Workers Compensation, is board certified in occupational medicine and professor in the Department of Emergency Medicine and School of Public Health at the University of Colorado School of Medicine. She gave an informative presentation on management of the patient with chronic non-cancer pain, which stressed the importance of having a multidisciplinary approach that may include a variety of medications, cognitive behavioral therapy, physical movement/exercise and patient education for better self-management.

Dr. Mueller suggested the patient’s focus should not be on “eliminating pain, but managing pain to restore physical and mental function and quality of life,” adding that this expectation tends to be more successful and lead to improved patient satisfaction. Just as Dr. Wright emphasized the importance of a patient’s “functional status,” Dr. Mueller endorsed the same to gauge the benefit of, or lack thereof, the treatment plan. In addition, she covered the recommendations for opioid use (one long-acting with one short acting, for break through) and warned of the combination of opiates with benzodiazepines due to a greater risk of adverse events. She suggested looking at the Washington state guidelines for chronic non-cancer pain management at www.agencymeddirectors.wa.gov.

A final presenter, Alan Lembitz, MD, vice president, COPIC Patient Safety and Risk Management, presented the importance of documenting your hx, PE, appropriate data, meds Rx, medical decision making and plan for all patients. “Your actions must match the documentation,” he said. Dr. Lembitz reported that the issues that cause providers the most problems with regard to medications are more likely to get them involved with the Colorado Board of Medical Examiners rather than with their liability carrier. As a last note, Dr. Lembitz showed a few slides about the profitability on the black market of prescription drugs, where oxycodone sells for $5-$10 per pill.

In summary, I would like to make a plea for all providers to take an active approach to this public health crisis. Let’s engage and communicate with our patients in the appropriate management of their pain, while doing our best to avoid the diversion of prescription medications. Let’s advocate for education, rather than regulation.

The webinar from this program will be available online until Jan. 15, 2013 at mms://essvideo.ucdenver.edu/public/Prescriber_Opioid_Training_NOV_15_2012.asf
The slides are available at www.peerassistanceservices.org on the right side of the home page via the link next to “access presentations.”

A special thanks to the Colorado Division of Behavioral Health, Peer Assistance Services, Colorado Prescription Drug Abuse Task Force, Colorado Medical Society CME unit, COPIC, CU Skaggs School of Pharmacy and Pharmaceutical Science (Rob Valuck), Colorado Pain Initiative, Occasions Catering, Laurie Lovedale, Helen Kaupang and all the volunteers who joined together to make this event a success.