Joseph Tu, Medical Director Chronic Pain Program, Cedars-Sinai
The opioid epidemic has recently gained a spotlight in the public eye and has resulted in political and healthcare policy changes. Its infamy lies in the fact that this epidemic is costing the United States, as a nation both economically and in lives lost. The societal and economic burden of chronic pain has been well documented affecting more than 100 million Americans, and with total direct and indirect costs ranging from $560 billion up to $635 billion per year.To put this into perspective, in terms of the landscape of chronic conditions, chronic pain affects more Americans than diabetes (29 million), coronary heart disease including strokes (18.7 million), and cancer (14.5 million) combined. In addition to economic costs, opioids are the most common prescription drug implicated in overdose deaths, involved in up to 75 percent of overdoses, and estimated to be responsible for at least 17,000 deaths annually. What is astonishing is that, in 2014, more than 240 million prescriptions were written for prescription opioids, which are more than enough to give every American adult their own bottle of pills. Needless to say, the United States government has made the opioid epidemic one of their priorities to address in the healthcare sector.
“The opioid epidemic prompted the CDC and other legislative entities to place recommendations and regulations around opioid prescribing and monitoring”
The opioid epidemic prompted the CDC and other legislative entities to place recommendations and regulations around opioid prescribing and monitoring. Much of the regulations center around monitoring the types of controlled substances, the dose, and the prescribing patterns of the practitioners to avoid multiple prescribers for controlled substances. More specifically, they recommended having a pain agreement to discuss the risks of being on opioid medication and other controlled substances, monitoring patient’s control substance prescription filling patterns on electronic data-base, and keeping the morphine equivalent daily dose (MEDD) below a recommended level as priorities of numerous health systems. The EPIC electronic medical record system, which is used by a number of medical systems and Universities, has developed some convenient tools to help practitioners and medical leadership to monitor and track opioid prescription. The features enabled administrators of health systems to learn what their practitioner’s opioid prescribing data are and if there’re any outliers. Many health systems were able to establish policies or recommendations based on the data they collected from the electronic medical records (EMR). Numerous large medical systems have done this and even went as far as using MEDDs of their patients on opioids to be goals for their institutions. Although on the surface it may look like these initiatives were set to ensure quality and safety in their patient care. However, there are potentially very serious unintended consequences with this approach. Additional editorials have been released by the CDC cautioning against this potential consequence. What many states observed was that these patients get abandoned due to their MEDD or placed on a weaning schedule that they cannot adhere to achieve institutional goals and adhere to guidelines or policies. This can result in the patients having decline in their function and quality of life or worse, end up using street medications and having increased adverse events or costing their lives.
The purpose of this article is to acknowledge the advancement in EMR systems by providing medical systems and practitioners with tools to better monitor and risk assess their patients in their opioid use and ultimately to lower their risk of death due to opioids. However, acquiring the data can at times have the opposite affect if practitioners and health systems grow fearful of this patient population and end up dismissing them due to the risks and liability. This in turn can end up making our efforts to save these patients to become counterproductive. This commentary, I feel follows the same lines as the most recent governmental corrective recommendations on their initial letter of recommendations surrounding the opioid epidemic. As we swing from the pendulum of medicine and public policies, real medicine seems to reside somewhere in the middle, centering around the patient.