Changes in Opioid Prescribing for Chronic Pain in Washington
Changes in Opioid Prescribing for Chronic Pain in Washington
Primary care providers in the United States find themselves at an important crossroads concerning opioid therapy for CNCP. For more than a decade, pain experts and organized medicine called for more adequate treatment of pain with opioids, which increased prescribing by physicians and other providers who treated patients with CNCP. Rates of use and daily doses of the most powerful schedule II opioids then rose dramatically. These increased rates of use—especially increased rates of high-dose use—have contributed to the public health epidemic of overdose morbidity and mortality that has occurred over the past decade.
In 2007, WA was the first state or jurisdiction to implement specific dosing guidance for opioids in the treatment of CNCP. It was also the first state to repeal the "Intractable Pain" laws that had legalized long-term opioid therapy without a dosing ceiling and to implement new laws and regulations reflecting generally agreed upon best practices. In a 2009 survey primary care physicians in WA reported that they rarely used most of these best practices and that they thought that more guidance and community resources, including dosing guidance, was needed. WA agencies and our collaborating clinical and academic advisors responded with an updated Opioid Dosing Guideline in June 2010, which contained tools needed to implement most of the best practices.
When the WA Opioid Dosing Guideline was first published online in April 2007, it received strong negative feedback from professional pain organizations and patient advocacy groups and a lawsuit was filed but was subsequently overturned. However, in the 2009 survey of WA primary care physicians, 86% reported that a yellow flag dose of 120 mg/day MED was reasonable (75%) or too high (11%), which is similar to the results of the current survey (71% and 16%, respectively). Of primary care prescribers who responded to the 2009 survey, 54% were concerned about dependence, addiction, and diversion. In the current survey, an even larger proportion of providers (72%) reported similar concerns. These concerns are consistent with survey data collected from primary care physicians in low-income clinics in the United States,Canada, and Veterans Affairs medical clinics. Thus, while primary care physicians generally express confidence in their ability to use opioids to treat CNCP, potential risks of dependence and addiction and lack of community and system resources are significant concerns.
In the current survey, providers in a large WA integrated health plan (GH) that has a long tradition of innovation in chronic care reported fewer concerns regarding opioid prescribing for CNCP. This is likely because of strong institutional support throughout the organization for adoption of best practices regarding opioid prescribing, including a risk mitigation initiative and prescribing guideline targeting patients receiving chronic opioid therapy that was implemented in October 2010. Although 3.3% of all providers statewide reported they had stopped prescribing opioids for CNCP, no GH provider in our survey reported doing so. While 16.7% of non-GH providers and 42.5% of Spokane providers reported that they "never or almost never" can access a pain consultation, only one GH physician reported such difficulty. When WA passed new opioid laws early in 2010, concern was expressed regarding regulatory scrutiny and potential overreach by the government. However, in the current survey, conducted about 1 year after passage of the law, only a minority of WA providers overall (25.3%) reported being very concerned about regulatory scrutiny. Among providers at GH, only 12.8% reported such concern. In Spokane, a community with less support for opioid prescribing and chronic pain management best practices, 29.2% expressed concern.
Although ARNPs may prescribe controlled substances in WA and in most states, this is the first report of opioid prescribing practices specific to ARNPs. Of the respondents in this survey, 39% were ARNPs. Overall, in our survey, ARNPs, as compared with physicians, were less likely to report prescribing opioids to the majority of their patients with CNCP, to have read/applied the WA Opioid Dosing Guideline, or to have available opioid policy tools or electronic health records in their clinical setting. Compared with WA physicians, ARNPs were more than twice as likely to have stopped prescribing opioids altogether to their patients with CNCP. The reasons for these differences are not clear.
Limitations of this study include the use of a convenience sample and a low response rate. The 2009 survey focused on acceptance and diffusion of the 2007 Opioid Dosing Guideline, whereas the current survey was expanded to include a focus on changing practices and needed resources. The addition of ARNPs to the survey sample and different methods of accessing respondents resulted in differences between the 2009 survey and the current survey that precluded ability to directly compare results.
Although questions remain concerning the long-term effectiveness of opioid therapy in people with CNCP, there is little question that more community-based resources will be necessary to effectively treat patients with CNCP. In this survey, the great majority of all prescribers reported enthusiasm for the diffusion of tools to help them manage patients with CNCP, including phone consultations with experts, web-based tools, web-based continuing medical education, and other advanced training, patient decision aids, and computerized programs to monitor prescription drugs. The current results also suggest a pressing need to increase capacity in the majority of communities that do not have the substantial resources required to effectively address chronic pain.
We have begun to develop such capacity through payment incentives for best practices and improved care coordination among injured workers in WA and by offering more efficient means of consultation, such as the use of video-linked consultations with panels of university-based experts. The prevention and adequate treatment of chronic pain should be considered in the same conceptual framework offered by leaders of integrated care management for other chronic diseases. As such, a medical home model to address chronic pain as a community-wide health delivery innovation should be considered. Insurers will be critical in developing incentives for best practices that could be effective alternatives to opioids in preventing and treating chronic pain, such as reducing patient avoidance of fear and promoting patient participation in customary activities, graded exercise, cognitive-behavioral therapy, and multidisciplinary intensive rehabilitation. In addition, incentivizing balanced, evidence-based provider education on these best practices will be necessary to help ensure their dissemination.
Discussion
Primary care providers in the United States find themselves at an important crossroads concerning opioid therapy for CNCP. For more than a decade, pain experts and organized medicine called for more adequate treatment of pain with opioids, which increased prescribing by physicians and other providers who treated patients with CNCP. Rates of use and daily doses of the most powerful schedule II opioids then rose dramatically. These increased rates of use—especially increased rates of high-dose use—have contributed to the public health epidemic of overdose morbidity and mortality that has occurred over the past decade.
In 2007, WA was the first state or jurisdiction to implement specific dosing guidance for opioids in the treatment of CNCP. It was also the first state to repeal the "Intractable Pain" laws that had legalized long-term opioid therapy without a dosing ceiling and to implement new laws and regulations reflecting generally agreed upon best practices. In a 2009 survey primary care physicians in WA reported that they rarely used most of these best practices and that they thought that more guidance and community resources, including dosing guidance, was needed. WA agencies and our collaborating clinical and academic advisors responded with an updated Opioid Dosing Guideline in June 2010, which contained tools needed to implement most of the best practices.
When the WA Opioid Dosing Guideline was first published online in April 2007, it received strong negative feedback from professional pain organizations and patient advocacy groups and a lawsuit was filed but was subsequently overturned. However, in the 2009 survey of WA primary care physicians, 86% reported that a yellow flag dose of 120 mg/day MED was reasonable (75%) or too high (11%), which is similar to the results of the current survey (71% and 16%, respectively). Of primary care prescribers who responded to the 2009 survey, 54% were concerned about dependence, addiction, and diversion. In the current survey, an even larger proportion of providers (72%) reported similar concerns. These concerns are consistent with survey data collected from primary care physicians in low-income clinics in the United States,Canada, and Veterans Affairs medical clinics. Thus, while primary care physicians generally express confidence in their ability to use opioids to treat CNCP, potential risks of dependence and addiction and lack of community and system resources are significant concerns.
In the current survey, providers in a large WA integrated health plan (GH) that has a long tradition of innovation in chronic care reported fewer concerns regarding opioid prescribing for CNCP. This is likely because of strong institutional support throughout the organization for adoption of best practices regarding opioid prescribing, including a risk mitigation initiative and prescribing guideline targeting patients receiving chronic opioid therapy that was implemented in October 2010. Although 3.3% of all providers statewide reported they had stopped prescribing opioids for CNCP, no GH provider in our survey reported doing so. While 16.7% of non-GH providers and 42.5% of Spokane providers reported that they "never or almost never" can access a pain consultation, only one GH physician reported such difficulty. When WA passed new opioid laws early in 2010, concern was expressed regarding regulatory scrutiny and potential overreach by the government. However, in the current survey, conducted about 1 year after passage of the law, only a minority of WA providers overall (25.3%) reported being very concerned about regulatory scrutiny. Among providers at GH, only 12.8% reported such concern. In Spokane, a community with less support for opioid prescribing and chronic pain management best practices, 29.2% expressed concern.
Although ARNPs may prescribe controlled substances in WA and in most states, this is the first report of opioid prescribing practices specific to ARNPs. Of the respondents in this survey, 39% were ARNPs. Overall, in our survey, ARNPs, as compared with physicians, were less likely to report prescribing opioids to the majority of their patients with CNCP, to have read/applied the WA Opioid Dosing Guideline, or to have available opioid policy tools or electronic health records in their clinical setting. Compared with WA physicians, ARNPs were more than twice as likely to have stopped prescribing opioids altogether to their patients with CNCP. The reasons for these differences are not clear.
Limitations of this study include the use of a convenience sample and a low response rate. The 2009 survey focused on acceptance and diffusion of the 2007 Opioid Dosing Guideline, whereas the current survey was expanded to include a focus on changing practices and needed resources. The addition of ARNPs to the survey sample and different methods of accessing respondents resulted in differences between the 2009 survey and the current survey that precluded ability to directly compare results.
Although questions remain concerning the long-term effectiveness of opioid therapy in people with CNCP, there is little question that more community-based resources will be necessary to effectively treat patients with CNCP. In this survey, the great majority of all prescribers reported enthusiasm for the diffusion of tools to help them manage patients with CNCP, including phone consultations with experts, web-based tools, web-based continuing medical education, and other advanced training, patient decision aids, and computerized programs to monitor prescription drugs. The current results also suggest a pressing need to increase capacity in the majority of communities that do not have the substantial resources required to effectively address chronic pain.
We have begun to develop such capacity through payment incentives for best practices and improved care coordination among injured workers in WA and by offering more efficient means of consultation, such as the use of video-linked consultations with panels of university-based experts. The prevention and adequate treatment of chronic pain should be considered in the same conceptual framework offered by leaders of integrated care management for other chronic diseases. As such, a medical home model to address chronic pain as a community-wide health delivery innovation should be considered. Insurers will be critical in developing incentives for best practices that could be effective alternatives to opioids in preventing and treating chronic pain, such as reducing patient avoidance of fear and promoting patient participation in customary activities, graded exercise, cognitive-behavioral therapy, and multidisciplinary intensive rehabilitation. In addition, incentivizing balanced, evidence-based provider education on these best practices will be necessary to help ensure their dissemination.
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