CDC- GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN

CDC’s Guideline for Prescribing Opioids for Chronic Pain is intended to improve communication between providers and
patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain
treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose.
The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf

Are patient satisfaction surveys fueling  dependence on pain killers?

If you’ve spent time as a hospital patient, you may recall receiving a survey about your experience. It turns out your answers can impact how much the hospital is paid and, in some cases, even what your doctor earns.

The government-mandated “patient satisfaction survey” is meant to reward quality and effective care, but some doctors say it has had an unintended consequence: fueling Americans’ dependence on prescription pain pills.

We met Dr. Mark Woodard in the ER at Bristol Regional Medical Center in eastern Tennessee. Appalachia is ground zero for in the country’s opioid abuse crisis. Two million Americans are hooked on pain pills, and overdoses kill more people than gun homicides, reports CBS News’ Brook Silva-Braga.

Woodward said he sees people seeking drugs on every shift.

“I mean, two or three today,” he said.

But turning away drug-seekers can be bad for business, some doctors told us, in part because of the rise of patient satisfaction surveys. In addition to asking if the nurses are polite and the hospital is clean, the survey has questions like: “How often did the hospital staff do everything they could to help you with your pain?”

Twenty-eight percent of doctors are paid bonuses based on patient satisfaction, according to the industry group physicians practice, and hospitals with better scores get bigger payments from Medicare and Medicaid.

Drs. Dana Barlow, Rimon Ibrahim and Joe Smiddy have practiced medicine in Appalachia for a combined 98 years and say more and more of their patients have become addicted.

“It’s getting worse year after year,” Ibrahim said.

Barlow said pressure on hospitals to score well led to pressure on doctors, including him, to prescribe opioids.

“How does that conversation go?” Silva-Braga asked.

“It goes basically, ‘We want to make sure that everybody in the emergency department is happy and their pain is relieved and so you need to do that,’” Barlow said.

“Do they say, ‘Let’s get the scores up?’”

“They tell you to get the scores up, yeah. I’ve seen physicians fired because of not adequately addressing pain management,” Barlow said.

Researchers at the University of Wisconsin found one in five doctors reported their jobs had been threatened over the scores. Some of them have ended up looking for work at the clinic Dr. Smiddy runs.

“We see physician applicants… who have lost their previous job because of the prescribing habits that were placed upon them that they weren’t comfortable with in a previous job,” Smiddy said.

In response to similar concerns, Medicare and Medicaid will stop paying hospitals based on their pain scores beginning October 1. But many hospitals will still use the scores to rate their doctors, using reports created by private survey companies.

Dr. Jim Merlino is the president of strategic consulting for the biggest of those companies, Press Ganey. He said comparing physicians makes doctors more accountable.

“Let’s say you’re a physician that doesn’t believe in giving a lot of pain medication. Are you going to allow a patient to sit in bed writhing in pain? Would you allow that? I wouldn’t. I would want to know as a provider or as a leader of a group or a hospital if that was happening to my patients,” Merlino said.

“So you do think its fine for doctors to be compared to other doctors based on these scores?” Silva-Braga asked.

“I think getting data points out to physicians is important, yes,” Merlino said.

Back in Tennessee, Woodard, who leads a group of ER doctors, has negotiated a compromise with his hospital. When patient satisfaction bonuses are calculated, questions on pain are stripped out.

“Why would you care about not being graded on pain? What difference would it make if you were?” Silva-Braga asked.

“Well, because it would put us under pressure. … Do I write this patient a small amount of narcotics where they’ll be happy with me and give me a good score where I can either keep my job or get a financial bonus? I think human nature says you’re under pressure to do that,” Woodard said.

Doctors groups told us those types of arrangements that ignore the pain questions are becoming more common. But with no national rules about how the scores are used it remains a hospital-by-hospital decision what to do about doctors with low pain management scores.

Source: Opioid epidemic: Are patient satisfaction surveys fueling America’s dependence on pain killers? – CBS News

Pain Management Survey Questions Will No Longer Impact Inpatient CMS Hospital Reimbursement Rates – AOTA

On October 1, 2017, the Centers for Medicare & Medicaid Services (CMS) announced they will no longer use results from the pain management portion of the Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) survey to impact reimbursement rates from the Hospital Value-Based Purchasing (VBP) program*. The Department of Health and Human Services (HHS) determined pain management questions may financially incentivize inpatient hospitals to overprescribe opioids in an effort to eliminate pain and improve survey results.

HHS intends to replace the current questions with questions targeted toward pain management communication similar to those in the Outpatient and Ambulatory Surgery (OAS) CAHPS. HHS will have public comment periods available during development and prior to implementation of the new pain management questions for the HCAHPS. The President’s Commission on Combating Drug Addiction and the Opioid Crisis supported this decision as part of their 56 recommendations released on October 31, 2017.

*For now, the pain management questions will continue to remain a part of the survey sent to patients and will be used when determining scores for the Hospital IQR program, HCAHPS star ratings, and Hospital Compare overall ratings. However, the scores will not impact reimbursements through the VBP program.

Source: Pain Management Survey Questions Will No Longer Impact Inpatient CMS Hospital Reimbursement Rates – AOTA

Fentanyl bust nets enough drugs to wipe out population of Ohio 

Police who busted a fentanyl ring in Columbus, Ohio found enough of the drug to kill the population of the entire city, prosecutors told Fox News.

Investigators ended up finding 4.5 pounds of fentanyl in a drug bust in October, which could have wiped out the city of about 800,000 residents.

But that’s not even close to what was found in the Ohio capital the following month when police seized 20 pounds of pure fentanyl.

“So it would probably be enough to kill all, the entire population in the state of Ohio,” Franklin County Prosecutor Ron O’Brien said.

Ohio has 11.6 million residents and, at 2 to 3 milligrams per lethal dose, the amount of fentanyl discovered in the November bust could potentially kill more than 9 million people.

“Two or three milligrams of fentanyl is not much more than five or six small grains of salt,” O’Brien said.

But the epidemic goes beyond Ohio. Some of the major opioid busts this year could have killed the entire populations of several states.

In New York, officials seized more than 140 pounds of fentanyl in August. The Drug Enforcement Administration said that amount could’ve killed nearly 32 million people — the populations of Texas and Oklahoma combined

In San Diego, close to 100 pounds of fentanyl were seized in June, enough to kill the combined residents of New York, New Hampshire and Maine — 22.4 million people. In St. Louis, nearly 60 pounds of pure fentanyl found in April could have killed 13.6 million people.

O’Brien said he knows the issue of opioid abuse extends beyond his city.

“That’s occurring not only here but across the country,” he told Fox News.

The Center for Disease Control’s latest drug report stated more than 33,000 people died from opioid-related drug overdoses in 2015. Close to 10,000 of them were from synthetic opioids such as fentanyl.

Researchers say the issue has moved beyond prescription opioids.

“We’ve tried to curtail the supply of prescription opioids but that has led users to move to illicit drugs like heroin and fentanyl,” Michael Betz, an assistant professor in the Department of Human Sciences at Ohio State University, told Fox News.

The ongoing battle against the epidemic is costing Ohio residents between $6.6 and 8.8 billion per year, Betz told Fox News.

“That’s roughly what the state of Ohio spends on its education for K through 12,” he said.

Betz said tackling the issue remains a challenge.

“How do you stop illegal supplies of illicit drugs?” he said. “I’m not sure we have many good answers to that right now.”

Source: Fentanyl bust nets enough drugs to wipe out population of Ohio | Fox News

West Virginia calls in National Guard to tackle opioid crisis | Fox News

People expect to see the Army National Guard during disasters.

In Huntington, W.Va., the guard has been called in to help tackle the opioid crisis — which the governor has described as a disaster.

“We have to stop this terrible drug epidemic,” West Virginia Gov. Jim Justice said. “We have to. If we don’t, it will cannibalize us.”

“I don’t think there is a police department in America that has all the resources they need,” Huntington Police Chief Hank Dial said. “It is a complex problem and it needed a complex solution.”

national guard helicopter

The National Guard is flying its Lakota helicopters on reconnaissance missions in coordination with local police, providing eyes in the sky during busts and while serving warrants.  (FOX News)

The guard is flying its Lakota helicopters on reconnaissance missions in coordination with local police, providing eyes in the sky during busts and while serving warrants.

But its primary role is technical and analytical support.

Guardsman, who asked not to be identified, are manning hotlines and working on computers inside Huntington Police Department’s Criminal Investigation Bureau, helping track down dealers and drug networks so cops can focus on the street.

On Wednesday, the guard answered a call that led to the bust of an alleged dealer and the recovery of 430 grams of fentanyl, far more powerful than heroin, with a street value of $86,000.

“We are solving a problem in our country,” said Maj. Gen. James Hoyer, a West Virginia National Guard commander. “And, at the same time, making sure we have the highest level of readiness to respond to something else that may be out there, somewhere else in the world.”

wv national guard 2

In West Virginia, the National Guard’s primary role is technical and analytical support. Guardsman, who asked not to be identified, are manning hotlines and working on computers inside Huntington Police Department’s Criminal Investigation Bureau, helping track down dealers and drug networks so cops can focus on the street.  (Fox News)

U.S. Rep. Evan Jenkins, R-W.V., said this drastic step is needed to make a dent in the raging opioid crisis.

“We have people’s lives at risk,” Jenkins said. “We have horrifically  lost way too many lives as result. It is a bold action but, you know what, we need to take action and we are doing that…”

There will not be Humvees blocking roads or soldiers on the street corners with long guns. But the guard could be deployed in this state for years – funded by the state – as long as cops say they need help.

Source: West Virginia calls in National Guard to tackle opioid crisis | Fox News

Emory hosts community conversation on America’s opioid crisis | Emory University | 

Debra Houry, director of the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control and a former associate professor in Emory’s Department of Emergency Medicine

  • As an emergency room doctor at Grady Hospital for 15 years, Houry’s views on the opioid epidemic have evolved. “Some say ‘We never saw it coming.’ I will say, ‘I kind of saw it coming,’” she said. Over the years, Houry saw a rise in patients arriving for opioid abuse, addiction issues, substance abuse disorders and referrals for pain management.
  • There are now about 230 million prescriptions for opioids administered in the U.S. on an annual basis. “That’s enough for every single adult to have a bottle of pills around the clock for three weeks,” Houry said. “That’s too much.”
  • About three years ago, Houry took on a CDC project to outline “Opioid Prescribing Guidelines for Chronic Pain,” which has helped decrease opioid prescriptions over the last two years. While the guidelines advocate prescribing non-opioid medications for chronic pain first, “we’re still at three times (opioid prescriptions) what we were at in 1999,” she said. “My concern is we primed the pump, so a lot of people became addicted to prescription pills and have then gone on to misuse heroin and now fentanyl, which we know is just killing people due to its potency.”
  • The CDC is now funding prevention programs across the country that work with health systems to employ syndromic surveillance to help identify non-fatal overdoses in emergency departments. The data are then used to issue health advisories and activate agencies to a quest to prevent fatalities. “My goal is to prevent people from getting addicted in the first place,” she said.

Source: Emory hosts community conversation on America’s opioid crisis | Emory University | Atlanta, GA

Revised HCAHPS Pain Management Questions: What You Need to Know

CMS has proposed removing the current Pain Management composite, which consists of the following three questions.

  • During this hospital stay, did you need medicine for pain?
  • During this hospital stay, how often was your pain well controlled?
  • During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

They are proposing replacing these questions with a new composite made up of the following three questions, which reflect communication about pain.

  • During this hospital stay, did you have any pain?
  • During this hospital stay, how often did hospital staff talk with you about how much pain you had?
  • During this hospital stay, how often did hospital staff talk with you about how to treat your pain?

The new questions were developed to address concerns expressed by hospitals and physicians that the wording of the current Pain Management composite encourages inappropriate prescribing of opioids. While the available evidence indicates that there is no relationship between opioid prescribing and patient experience scores, the revised pain composite shifts the focus to evaluations of pain and discussions about pain treatment options.

Source: Revised HCAHPS Pain Management Questions: What You Need to Know

FDA targets anti-diarrhea pills that Lehigh Valley doctor calls ‘poor man’s methadone’ – The Morning Call

An emergency room doctor with Lehigh Valley Health Network last year treated two people who nearly died from taking large quantities daily of an over-the-counter anti-diarrhea medication in an effort to get high or stave off the effects of opioid withdrawal.

The two people who overdosed on loperamide, the active ingredient in the anti-diarrhea medication sought by opioid addicts when they cannot get their drug of choice, so alarmed Dr. Kenneth Katz that he contacted a manufacturer of loperamide. He told the company its product represented “a public health hazard.”

To raise awareness on the issue, Katz also co-wrote an article last year about the two near-fatal cases for The Journal of Emergency Medicine.

Last week, the U.S. Food and Drug Administration took steps designed to limit the abuse of loperamide, the active ingredient in anti-diarrheal medications like Imodium.

In a new drug safety warning, the FDA stated the agency continues to receive reports of “serious health problems and deaths with much higher than the recommended doses of loperamide, primarily among people who are intentionally misusing or abusing the product, despite the addition of a warning to the medicine label.”

The agency said it will work with loperamide manufacturers to limit the number of doses in a package and by using blister packs to make it more cumbersome to take large quantities of pills.

The FDA said loperamide overdoses accounted for about a dozen deaths across the nation.

The Lehigh County coroner’s office noted two deaths from loperamide overdoses, one in 2017 and 2016. There were no fatal loperamide overdoses in Northampton County, according to that county’s coroner’s office.

In earlier warnings, the FDA stated that taking higher than recommended doses of the medication could cause serious heart conditions that lead to death.

Loperamide is regarded as “a poor man’s methadone,” to help opioid withdrawal symptoms, said Katz, the LVHN doctor.

In the journal article, Katz details the two overdoses he treated without naming the patients.

“It is a case study of two patients who suffered from heart effects of excessive amounts of loperamide use. Each one nearly died,” Katz said. “It comprises the growing literature describing the obvious toxicity of excessive amounts of loperamide, undoubtedly influencing the FDA to issue its warning.”

Katz’s article described the two people who overdosed:

• A 28-year-old man with a history of depression and substance-abuse disorder came into the emergency room with shortness of breath and lightheadedness. He “ingested large amounts of loperamide daily,” and was admitted to the intensive care unit and needed an external pacemaker.

• A 39-year-old woman who also suffered from depression and admitted taking large amounts of loperamide daily. She suffered from seizure-like activity and was also admitted to the intensive care unit for treatment.

Since treating those two cases, Katz said, he has not treated any others, but that doesn’t mean loperamide isn’t still be abused.

“It could be that some are using less and figuring out how to use loperamide differently as well,” he said. “Remember, there are patients who have died before even receiving medical care, so we in the emergency room might never see them.”

He said the safety measures proposed by the FDA to curb loperamide abuse are similar to the crackdown against Sudafed, a key ingredient to produce methamphetamine.

“Both are valuable drugs that can be diverted for illicit purposes,” Gallagher said.

Katz said he was glad to hear of the FDA’s new guidelines.

“It’s a start, ultimately,” Katz said. “However, I feel loperamide should be moved behind the counter to further lessen its abuse.”

Anti-diarrhea pills that Lehigh Valley doctor calls ‘poor man’s methadone’ – The Morning Call

Hospitals using alternative for Morphine due to shortage | wwltv.com

Eyewitness News recently got calls and e-mails from some concerned hospital patients wanting to know if they were getting the right pain medication alternative, since morphine is in short supply.

When a recent hospital patient was at Tulane Medical Center last week, he was told there was no morphine for pain.

“When you go into the emergency room and they treating you, they automatically saying they don’t have morphine and they’re giving you Narcan with the Fentanyl,” said the man who did not want to give his name on camera.

He got concerned when he heard the word Fentanyl.

“It concerns me when it’s popping on the television every time about being used on Fentanyl. They got more people dropping and hitting the ground using Fentanyl then they have doing heroin,” he said.

Another person, who didn’t want to go on camera, called to say a relative was at Ochsner Hospital and was also told they were out of Morphine, and were going to use Fentanyl.

Doctors explain that there is a morphine shortage, locally and nationwide, partially because of changes in the pharma industry and because the hurricane in Puerto Rico knocked out production at factories that make needed drugs, medical devices and supplies. But the medical director of University Medical Center says patients should not be concerned.

“Fentanyl is used in all areas of the hospital. It’s used for brief procedures. It’s used in the emergency department, and it’s used in the operating room as well,” explained Dr. Peter DeBlieux, The Medical Director of UMC and an Emergency Medicine Specialist at LSU Health Sciences Center.

Fentanyl, Dilaudid and Morphine are all opioids used to treat pain. The Fentanyl is used even when there is no morphine shortage, such as when a patient is allergic to it. It comes from a reputable manufacturer, the dose in a hospital is closely monitored, and the patient is under supervision. It is not at all like the unknown content on the streets that is mixed with heroin and abused causing deaths.

“The safety profile for Fentanyl is no different than it is for morphine, is no different than it is for Dilaudid ,” said Dr. DeBlieux.

“They saying they can’t get it (Morphine) from the manufacturer for another 30 days,” the recent patient said he was told at the hospital.

Patients should be reassured the shortage will not change their treatment. Doctors say the pain medications can be administered as a pill, IV drip, or injection.

Tulane Medical Center gave the following statement about how they are handling the national morphine shortage:

Source: Hospitals using alternative for Morphine due to shortage | wwltv.com

B-N Doctors Think Twice On Painkillers Amid Opioid Epidemic | WGLT

Dr. Ramsin Benyamin views the opioid epidemic almost like he would a patient. If you ask Benyamin how he’d fix the opioid issue—how he’d treat it—he starts with a diagnosis.

Before you can fix the problem, he said, you must understand how we got here.

“There is no one magic wand that you’re going to wave and the problem is going to disappear,” said Benyamin, president of the Millennium Pain Center, which has a location in Bloomington, and an assistant professor at the University of Illinois at Urbana-Champaign College of Medicine. “This is a problem that’s grown gradually, and there’s multiple aspects to it.”

The opioid epidemic has already changed the way Bloomington-Normal doctors treat their patients—from emergency room physicians to pain specialists like Benyamin. Doctors on the front lines are thinking twice about the quantities of opiate painkillers they prescribe, and they’re abiding by a new state law requiring them to a check a patient’s prescription history before giving them narcotics.

“There is no one magic wand that you’re going to wave and the problem is going to disappear.”

The overprescription of opiate painkillers is widely considered one of the drivers of the current opioid epidemic. Many addicted patients get their first exposure from a legal prescription, then moved on to higher dose formulations or more accessible illegal street drugs, the FDA says.

This can have deadly consequences, especially as lab-manufactured drugs are added to traditional heroin. Opioid-related deaths more than doubled in 2017 in McLean County to 34 from 15, said McLean County Coroner Kathleen Davis. Seven others died of overdoses involving other drugs.

Doctors have been talking about opioid abuse for at least a decade, said Benyamin, a nationally known pain expert whose Millennium Pain Center has seven locations around Illinois. The media and policymakers are latecomers to the discussion, he said.

The problem traces back as far as 2000, Benyamin said. That’s when the Joint Commission, which accredits and certifies medical facilities, issued new standards for treating patients with pain, he said. That increased focus on pain—when pain became a “fifth vital sign”—is what triggered a sharp increase in prescribed opiate painkillers, he said. Pharmaceutical companies seized the moment, he said.

“There’s a reason why we got here,” Benyamin said.

That focus on pain led doctors to opiate medications, said Dr. Kelley Smith, an attending physician in the emergency department at OSF St. Joseph Medical Center in Bloomington. Like many young doctors, Smith was trained that pain is the fifth vital sign. That’s led to a practice where it’s “easier to give out the pain medication and kind of move people along, instead of sitting down to address the underlying issue.”

If someone truly needs a painkiller, Smith will prescribe it, she said. But the headline-making opioid epidemic now gives front-line doctors like Smith pause about how much they’ll prescribe.

“I will definitely give it a second thought of how much I’m going to prescribe, and what is a reasonable amount for a person to take,” Smith said. “A big part of it is figuring out other ways that people who are using narcotics for pain medications, figuring out how to get them into pain management clinics or other ways to deal with their pain rather than turning to a pill.

“Really we want to treat the underlying problem, and we don’t want people to have to chronically be on medication to do it,” Smith added.

Some of this isn’t optional. As of Jan. 1, a new state law requires drug prescribers to use a database containing patient prescription histories. Physicians who don’t may be subject to state disciplinary action.

Smith did her residency at Southern Ohio Medical Center in Portsmouth, Ohio, where the opioid epidemic is at its worst. She rarely worked a shift there without seeing one or two overdoses.

“Part of the reason it got so bad in Ohio was that there wasn’t a lot of oversight with how many prescriptions could be written, for how much, for how long. So I think that’s one thing that’s already been addressed here (in Illinois),” Smith said.

A related problem is the shortage of effective pain medications that are not opioids, Benyamin said. Insurance companies sometimes do not cover non-opioid alternatives, he said. He recently tried to get Medicaid to cover a non-opioid inflammatory patch for a pain patient, a safer treatment with fewer known side effects. A 30-minute phone call later, Benyamin was told Medicaid doesn’t cover that, only a fentanyl (opioid) patch.

“Imagine that,” he said. “If you’re looking for a solution, you have to address all these issues.”

The worsening opioid epidemic has led to new discussions about pain management protocols across the medical community, Benyamin said. More recent CDC guidelines on dosing have been welcomed by the medical community, he said. Benyamin is past president of the American Society of Interventional Pain Physicians, which contributed to the CDC guidelines.

He said the problem is not just overprescribing—it’s co-prescribing, an issue identified in the CDC guidelines. Benyamin said doctors need to be careful about prescribing opiate painkillers alongside other medications that are considered central-nervous system depressants, like Xanax or valium.

“They make the impact even more serious,” Benyamin said.

There are also not enough resources available to treat addiction, Benyamin said. Insurance companies sometimes don’t cover treatment, he said. Benyamin is also baffled how easy it is for Chinese synthetic fentanyl to be imported into the U.S., worsening the opioid crisis.

“It’s unbelievable how this happens,” he said.

Source: B-N Doctors Think Twice On Painkillers Amid Opioid Epidemic | WGLT

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