Lesson 3: What clinical approaches are used to address the crisis?

You must first complete Lesson 2: Interactive Timeline of the Opioid Crisis before viewing this Lesson

Lesson Goal

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For you to become familiar with the clinical approaches and initiatives and programs being used to address opioid addiction and the opioid crisis.


Lesson Summary

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As the extent of the crisis has become clear in recent years, there has been a push to identify needed changes in treatment practice. These efforts can be grouped into:

  • Efforts focused on changing physician prescribing behavior
  • Increasing the effectiveness of addiction and recovery treatments

The Big Topics in This Lesson

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1- Efforts to change physician prescribing behavior

2- Improving the effectiveness of addiction and recovery treatments


Lesson Video

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Lesson Q & A

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Click on each question to learn more

Q1: What efforts are being made to change physician prescribing behavior?

One of the key lessons learned from the opioid crisis is that physicians play a critical role in preventing addiction in the first place. Much of the best practices research being promoted today involves getting physicians to adopt newer guidelines designed to use more conservative pain management practices.

Avoid using opioids for moderate pain- One of the most effective tools against the crisis is prevention. If patients can avoid becoming addicted in the first place they can avoid all the other negatives of addiction. This approach seeks to change way initial use is managed to prevent addiction in first place.

Along these lines, new prescribing rules are often adopted at the state level (or by large providers groups, hospitals etc). Key rules of preventive and conservative prescribing rules include:

  1. Only prescribe opiods for severe/acute, not for mild/morderate
  2. Try non-opioids medications first (Tylenol, advil, etc)
  3. Reduce initial days supply and level of potency (lower Morphine Milligram Equivalents, or MMEs)
  4. Try alternatives to medications for pain management, including lifestyle adjustments, behavioral therapy, acupuncture, massage or chiropractic services
  5. For inpatient settings, increase monitoring of opioid dosing in inpatient settings to see if patients really need the opioids
  6. More active post-overdose case management - Follow-up next day to get member into treatment, including scheduling assistance
  7. Proactive step down efforts for patients already on long term opioids

 

The chart below shows the predictability of addiction based on the days supply of the very first prescription.

 

1 & 3-yr Probabilities of continued opioid use by # days supply of 1st Rx

 

20% of patients with an initial 10-day supply will become long-term users

 

 

Most of the revised guidelines recommend lower MMEs and lower days supply for initial prescriptions.

In one example, Maine passed laws to cap the MMEs and days supply of prescribed opioids.

Revised guidelines from HHS agencies- Federal health agencies have updated their guidelines and strategic focus areas in response to the crisis. Examples include:

  • CDC published the "Guideline for Prescribing Opioids for Chronic Pain" in 2016. This document recommends prescribers weigh the risks and benefits of opioids only for pain management for each patient; starting with the lowest effective dose; and avoiding prescribing opioids and benzodiazepine at the same time
  • CMS published guidelines related to opioids after surgery. CMS recommends patient education, assessment of risk for addiction and monitoring plans
  • HHS and The National Institutes of Health refocused its efforts on addressing the crisis on 5 major priorities (see graphic)

One study of a large provider groups prescribing system discovered that default opioid prescription orders were very high. By changing default values on days supply and MMEs in the electronic system, the practice went from prescribing 88,000 opioid tablets per month down to 67,000 (a 30% decrease).

Requiring opioid manufacturers to pay for provider education- The US Food and Drug Administration (FDA) now requires the makers of drugs like oxycodone to pay for educational programs that help physicians understand the risks of addiction.

Use PDMP databases to identify drug-seeking patients- A prescription drug monitoring program (PDMP) is a database with information on prescriptions of controlled substances. It allows doctors to identify doctor shopping for pills and other addiction patterns. As of the time of this class, 27 states require physicians to register with their PDMP. And 30 states required doctors to use it at least some of the time. For patients that are suspected to be at risk of addiction or abuse, many experts recommend use of pain agreements.

 

Q2: What efforts are being made to increase the effectiveness of addiction and recovery treatments?

As the opioid crisis has brought new attention to addiction, clinicians and program operators are re-examining the best ways to optimize effectiveness of treatment models.

 

  1. Invest in prevention upstream before addiction happens
    1. Educate providers on the risks of addiction with opioids
    2. Focus on education and prevention efforts for patients
    3. Include prevention of addiction in discharge planning
  2. Medication assisted treatment
  3. Use a chronic condition treatment model for addiction and recovery patients

 

Medication Assisted Treatment (MAT) is considered a critical component of success – Recent studies show that using medicines designed to assist in addiction recovery is critical to have long-term success. While MAT is not a stand-alone therapy, it has clear benefits when part of an overall treatment program. Perhaps most importantly, MAT reduces all-cause mortality and relapse.

 

This chart shows the impact of not using MAT (the green line)-

2015 Massachusetts study (Medicaid specific)

 

 

Medicaid Dictionary

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 New Terms from this lesson:
  1. National Institute of Health (NIH)– a large biomedical research agency in the U.S. Department of Health and Human Services.
  2. Evidence-based model– healthcare practice model based on a combination of research, clinician experience, and patient characteristics, situations and preferences.
  3. Prescription drug monitoring program (PDMP)– a database with information on prescriptions of controlled substances that allows doctors to identify situations of doctor shopping for prescriptions and other addiction patterns.

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