The Centers for Disease Control and Prevention’s new recommendations that strongly advise against the use of opioids for managing chronic pain have put hospitalists and other healthcare providers in the difficult position of turning to sometimes less effective treatment options.
Given today’s opioid epidemic, exercising caution when prescribing these drugs is important, but under- or inadequate prescribing will lead to poor pain-control outcomes, and potentially serious consequences for the subset of patients who might have benefited from opioid therapy.
In particular, we should not let the CDC guidelines and efforts to remove pain questions from satisfaction surveys derail access to opioids for those who need them for appropriate pain management. The Joint Commission standards encourage organizations to establish education programs, training, and policies and procedures that improve the assessment and treatment of pain. These standards recognize the role that opioids play in pain management, without promoting their unnecessary or inappropriate use.
The price of poor pain management
Recently, Sen. Richard Blumenthal and a number of Democrats and Republicans supported a bill to remove pain management questions from hospital satisfaction surveys. While this might protect hospitals from the consequences of undertreating pain, it puts patients experiencing pain from surgeries, trauma, cancer or terminal illness at risk. This bipartisan legislation overlooks the fact that satisfaction with pain management now measured by these surveys is vitally important from the patient’s perspective in terms of quality care. Undertreating pain can lengthen hospital stays, or contribute to avoidable readmissions that lead to penalties for providers.
Finding balance when treating pain
What’s needed is a multidimensional approach to pain relief, while allowing hospitalists to safely prescribe opioids when necessary. A good example: the Virginia Hospital & Healthcare Association’s board of directors recently formed a task force to ensure that medications prescribed to patients are taken as intended and not misused.
Without such efforts, and with too few pain specialists, there is the very real danger that prescribers will opt out of prescribing altogether. Chronic pain patients who would benefit from opioid therapy, or those who have successfully been managed with opioids, could struggle to find physicians willing to prescribe to them. These same patients may continue to seek relief (not necessarily from opioids) through visits to emergency departments, doctor’s offices and ambulatory care centers that may not be well-equipped to handle them.
Here’s another big concern: If widely adopted, the CDC guidelines could have a negative impact on cancer, palliative and end-of-life patients. Opioids play a critical role in relieving suffering for these patients, and while they are listed as exceptions in the guidelines, access to prescribers or pharmacies willing to stock opioids might become a challenge.
Pain management strategies
What can be done? Hospitals must invest in providing training and other resources to hosptialists and other prescribers. They also need a thorough understanding about the increased risk of abuse among opioid-naïve patients at hospital discharge, as well as how to assess for addiction risk factors. Likewise, physicians should inform patients of this risk prior to prescribing opioids, and limit the quantity that they prescribe, as one study recommended. Patients who require opioids, however, should not be overlooked in a zealous attempt to curtail opioid prescribing.
It’s also important for clinicians to check the state’s monitoring system prior to prescribing opioids, especially in the emergency department or upon discharge, and develop or expand programs that provide non-drug options for the management of chronic pain, such as behavior modification programs, cognitive therapy and graded exercise programs. Health plans also must cover these ancillary services so that patients can afford to access pain management options other than relying solely on drug therapy.
Across the country, hospitals are working to reduce the opioid epidemic by employing strategies to fight this serious public health problem. To assist these efforts, the American Hospital Association and CDC have created a new patient education resource about prescription opioids.
In the face of a growing national opioid epidemic, the best approach to the management of chronic pain is to establish the long-term safety and efficacy of opioids, improve prescribing methods and access to opioid prescribing databases, develop evidence-based alternative therapies, and offer providers and patients educational resources. In the meantime, hospitals and healthcare providers should not let the new CDC guidelines lead to the undertreatment of patients in pain--and set healthcare back years, if not decades, in terms of pain management. We need to explore new approaches while preserving the progress that has been made.
Terri Maxwell, Ph.D., APRN, vice president of clinical education at Enclara Pharmacia, oversees and contributes to the development of resources to assist hospice partners in providing evidence-based symptom management and palliative care to their patients.