Accidental drug overdoses that result in deaths have been rampant across the country. "It's a huge problem," says Gilligan of MGH
Mathew, the Christiana Care physician, says it is essential for healthcare leadership to overcome obstacles like potential drug overdoses to improve pain management. Pain care itself is "one of the biggest opportunities for improvement in medicine in healthcare, and the place where we just don't have adequate rules in the game because everybody's perception of pain is different and what the
Success key No. 1: Dealing with prescription drugs
Arnold Feldman, MD, a longtime interventional pain specialist in Baton Rouge, La., didn't want to be associated with the word pain. Indeed, he removed the word from his practice sign several years ago and replaced it simply with "The Feldman Institute." While he continues to treat patients afflicted with pain, specializing in interventional pain management outpatient procedures, he wants to distance his practice from less scrupulous providers.
Law enforcement, especially the U.S. Drug Enforcement Administration, is increasingly scrutinizing physicians because of so-called drug or pill mills, physician practices that overprescribe powerful drugs that are linked to the abuse of painkillers. Opioid analgesics—including morphine, oxycodone, and methadone—are among the prescription drugs most often linked to abuse.
Drug overdose death rates in the United States have more than tripled since 1990, "and have never been higher," according to the Centers for Disease Control and Prevention. Nearly three in four prescription drug overdoses are caused by opioid pain relievers, the CDC states. The misuse and abuse of prescription painkillers was responsible for more than 475,000 ED visits in 2009, a number that nearly doubled in five years.
"[Law enforcement] are scrutinizing doctors like crazy," Feldman says. "We don't want to be associated with drug or narcotics mills." Law enforcement's focus has prompted many primary care physicians to shy away from prescribing pain pills at all. "Family doctors used to treat people with pain," he explains. "They will not anymore. One of the reasons is poor education about opioids and the fear of government scrutiny and prosecution."
Hospitals, too, are specifically organizing pain treatment programs not only to relieve pain but also to coordinate care that thwarts potential abuses. The American Medical Association has called for a multidisciplinary clinical approach to the treatment of chronic pain with a focus on responsible prescribing of opioids. Physicians, hospitals, and health systems also are touting nondrug therapies and integrative approaches to treat pain without narcotics.
The government has taken steps to assist hospitals in overcoming problems with opioids. The Joint Commission, for instance, issued a Sentinel Event Alert that urges hospitals to take specific steps to prevent serious complications or even deaths from opioids. A growing number of states are enacting policies that promote the delivery of effective pain management, according to an American Cancer Society Action Network report.
Pain treatment programs are focusing on medication reconciliation as a key element in helping to improve treatment of patients and combat overprescribing of drugs. Such programs are often linked to sophisticated electronic medical records that keep tabs on patient usage of drugs and physician prescribing.
"We have made a huge effort in our center the past several years to have our medication reconciliation be more effective," says Gilligan of MGH. Under the protocol, patients are evaluated and educated about the impact of their medications. The dosages and the responses are registered in medical records. The medical record indicates what medication is appropriate and what interventions are needed.
"Every single time, someone goes over what medications [patients] are taking, what those medications do, and this is done even before the doctor sees them, and [the doctor] again goes over it all," Gilligan says. As they leave the hospital, patients review a summary report. The physicians are monitored, too. If a physician makes a mistake related to the dosage ordered, "the EMR triggers a response. It isn't perfect, but it greatly reduces the chances for errors."
General practitioners and nurses aren't the only team members involved in medication reconciliation, Gilligan says. "If a patient has behavioral or mental health issues, and not just the chronic pain, there are people on staff to deal with that—psychologists and psychiatrists. The psychiatrists have additional training in pain and substance abuse." Neurologists also are included in the pain unit, he says.
Barnes-Jewish Hospital routinely updates prescribers, interns, residents, and nurse practitioners in the hospital about patients' medications, especially for those patients transferred from one area of the hospital to another. With its medical record, the hospital's pain management center coordinates medication the patients take in the home and hospital.
Barnes-Jewish Hospital also implemented the Pasero Opioid-induced Sedation Scale to improve assessment of opioid medication administration in non-ICU inpatient nursing units. "A lot of us are moving away from opioids as a frontline therapy," says Bottros. "We have a system-based approach."