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Taking Aim at the Opioid Problem

April 28, 2016
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Pediatric specialists offer practical advice for protecting vulnerable patients from a growing epidemic.

The opioid epidemic in the United States is so widespread that even parents and teachers are now being issued opioid overdose kits complete with naloxone.

It’s in rural communities, suburban neighborhoods and inner cities. It’s so far-reaching that physicians and non-experts alike are being called to work together to save a generation. And the answers to hard questions are not illuminating a clear path to a solution.

Now, clinician-researchers at Nationwide Children’s Hospital are working with regulatory groups and an organization-wide taskforce to take on the growing opioid problem. The newly formed Opioid Safety Taskforce began gathering and tracking baseline data, working with the community and legislature, and educating families in early 2016.

The state of Ohio has one of the highest rates of painkiller prescriptions in the country, with physicians writing enough prescriptions for opioids on average to give at least one script to every person in the state.

The Opioid Safety Taskforce’s first objective was to survey prescribing physicians to generate a baseline of prescribing practices.

“We need to get a sense of where we are as an organization and a community,” says Sharon Wrona, DNP, administrative program director of the Comprehensive Pain Management Clinic at Nationwide Children’s. “Looking at the survey results, we’re able to identify some areas where practice differs from the recommendations and best practices that we’ve been using at our hospital. Because the Comprehensive Pain Clinic is on the front lines of treating children and adolescents with chronic pain, we’ve developed best practices here that help us to protect and support our patients.”

Changing Guidelines

According to the Centers for Disease Control and Prevention (CDC), existing guidelines for prescription opioid use vary. Primary care providers also report insufficient training regarding prescribing practices of opioid pain medication.

This prompted the CDC to develop new prescribing guidelines, which were released in March 2016 after months of controversy.

The CDC guidelines, which are focused on opioid use for chronic pain excluding end-of-life care and cancer, recommend that opioids not be treated as a routine first choice for pain management and that they be offered only for short periods of time and in low doses after other modes of treatment have failed. This is a sentiment with which Dr. Wrona whole-heartedly agrees.

“Opioids are not our first-line choices for chronic pain,” she says. “We use steroids, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, antiseizure medications, muscle relaxants, as well as complementary strategies such as aromatherapy, massage, acupuncture, and physical therapy. We also use psychology and talk therapy as a component of pain management.”

“Cancer is the main exception to the rules when it comes to managing chronic pain,” says Timothy Smith, MD, interim director of the Comprehensive Pain Management Clinic. “When it comes to managing cancer pain, the benefits of opioids are known to outweigh the risks. Controlling cancer-related pain is essential to supporting a child through cancer treatment.”

State-level prescribing guidelines fall in line with the national CDC guidelines, calling for physicians to prescribe only a minimum number of pills, discouraging automatic refill and recommending reevaluation of patients prescribed opioids at certain checkpoints.

But none of the existing guidelines are specific to pediatric patient populations.

“The pediatric population is a diverse group with complicated needs,” says Dr. Wrona. “Additional guidelines are needed for children and adolescents.”

Timothy Smith, MD, interim director and Sharon Wrona, DNP, administrative program director of the Comprehensive Pain Management Clinic at Nationwide Children's

Best Practices

At Nationwide Children’s Comprehensive Pain Management Clinic, clinicians have been creating and following guidelines and best practices regarding opioid prescription and monitoring.

OPIOID AGREEMENT

One of the first things Drs. Smith and Wrona recommend for practices or clinics that treat patients with opioids is an opioid agreement. While this type of agreement is not legally binding, it serves as a contract among the patient, provider and parent. The agreement dictates that the patient will only get medications from the clinic and will submit to drug tests.

“It’s not a perfect solution, but it lays the groundwork for the patient-provider relationship,” says Dr. Wrona. “The opioid agreement starts the conversation and makes clear our expectations.”

RISK ASSESSMENT AND AWARENESS

Dr. Smith suggests performing risk assessments, such as the Screener and Opioid Assessment for Patients with Pain (SOAPP), annually. “This is just one way to assess and track risk. It is also critical to talk about risks with your patients and families,” he says.

“Be aware. Know what’s being done with the medications you prescribe,” says Dr. Smith. “It’s unfortunate, but in some cases, it’s the parents diverting the meds.”

OARRS REPORTS

Since 2012, physicians have been encouraged to use Ohio’s Automated Rx Reporting System (OARRS) to see a patient’s other prescriptions for controlled medications. OARRS is a database that stores all controlled substance dispensing and personal furnishing information.

“We recommend that providers check the OARRS report at every patient encounter, especially when prescribing opioids,” says Dr. Wrona. “Armed with the information in the report, you may be better able to discourage ’doctor shopping’ for pain medications.”

“We check the OARRS report for our patients at every visit,” adds Dr. Smith. “We are able to see if they are getting medications from any other prescribers and how often they are filling their prescriptions. Patients and families may be less than forthright about other prescriptions they have from other providers if they are diverting or abusing the medications.”

Reviewing the OARRS report with the patient and family may be a way to open the conversation about safe habits, non-opioid adjunct therapies and risk factors.

STORAGE AND DISPOSAL EDUCATION

Doctors have been heavily criticized for prescribing more pills than a patient may need, particularly after surgery or in an acute pain situation. Because many people don’t know how to properly dispose of their prescription pain medications, the leftovers typically sit in the medicine cabinet, unlocked and easily accessible.

To prevent accidental ingestion or theft, the FDA recommends storing medications, including controlled substances, in lock boxes. When the medication is no longer needed, it should be disposed at a drug take-back site. “When we write the prescription, we need to talk about what to do with any leftover pain medication,” says Dr. Smith. “Education and access are key to getting patients and families to participate in safe disposal practices.”

“Drug take back days occur two to three times a year around Ohio, and many police stations — as well as a few pharmacies — are starting to install take back boxes,” says Dr. Wrona.

According to Dr. Smith, the biggest barrier to safe disposal is security. “Many times, prescribers don’t want the responsibility of being a drug take-back site or having lock boxes for safe disposal in their facilities, because it is a liability and they could become targets for robberies.”

When Addiction Happens Anyway

Guidelines are essential because, despite problems with misuse and abuse, opioid pain medication has a place in the physician’s arsenal. And not everyone who uses prescription opioids will go on to abuse them or become addicted.

However, it can be difficult to know who will go from use to abuse. And, if addiction does occur, providing access to treatment is equally important to preventing opioid abuse.

“It’s important to remember that many patients use opioid pain medications — sometimes for extended periods of time — without crossing the line from use to abuse,” says Steven Matson, MD, who leads the Medication Assisted Treatment for Addiction (MATA) Program at Nationwide Children’s. “We know that there is something uniquely biological about addiction, and it can be difficult to know what the triggers will be that will flip that switch.”

The MATA Program is an outpatient program for adolescents and young adults aged 14 to 21 years who are addicted to prescription opioids or heroin.

 

"Most of these kids need something that looks like a serious substance abuse program. We work with community organizations and behavioral health specialists to ensure kids are getting the help they need." — Steve Matson, MD
Steven Matson, MD, chief of Adolescent Medicine

“Most of these kids need something that looks like a serious substance abuse program,” says Dr. Matson, who is also section chief of Adolescent Medicine at Nationwide Children’s. “We work with community organizations and behavioral health specialists to ensure kids are getting the help they need.”

An end to the epidemic of opioid abuse and addiction will come from all sides: regulations, guidelines, prescribing practices, treatment opportunities and social awareness and support. The problem is complex, and millions of lives are at stake.

“No single intervention is going to fix the problem,” says Dr. Wrona. “But, providers who are writing prescriptions and helping patients manage pain, stressors and overall wellbeing are in a unique position to generate change.”

 

References:

  1. Koh, H. Community Approaches to the Opioid Crisis. JAMA. 2015 Oct. 13;314(14):1437-1438.
  2. IMS, National Prescription Audit, 2012
  3. Ohio Mental Health & Addiction Services. Opioid Prescribing Guidelines.
  4. National Institute on Drug Abuse. Monitoring the Future Study: Trends in Prevalence of Various Drugs.

 

Photo Credits: Adobe Stock (pill bottle); Nationwide Children’s (portraits)