The news is filled with evidences of the opioid crisis facing the United States.  We read about announcements of the arrest of healthcare providers.  Pharmacies are filling millions of prescriptions for opioids in towns with only 15,000 people.   The world supply of certain opioids is consumed only by the United States and the list goes on.

The following article announces the arrest of Nurse Practitioners and Physicians for abusive prescribing of opioids.http://www.clarionledger.com/story/news/local/2017/05/17/nurse-practitioners-charged-doctors-surrender-licenses-prescription-drug-investigation/328394001/.

The following article addresses the Food and Drug Administration’s new policy on opioids:  http://www.medscape.com/viewarticle/858411?src=wnl_tp10n_161227_mscpedit&uac=81691HV&impID=1262676&faf=1.

The last article announces a lawsuit by Ohio’s Attorney General against drug companies who market opioids:  http://www.foxnews.com/health/2017/06/01/ohio-attorney-general-sues-5-drug-companies-related-to-opioid-crisis.html.

In this eighth part of our series on opioids, we would like to propose a solution which will focus each of the contributors to this problem as described below. I am not sure, at this time, what I think about the lawsuit announced in the last of the above articles but even if the Attorney General wins the lawsuit and even if millions of dollars in fines are paid in the settlement, the profitability of this epidemic is so great, it will do nothing to solved the problem.

In my opinion, there are five categories of culprits in the Opioid crisis. In ascending order of responsibility, they are:

1. Drug companies
2. Pharmacies
3. Physicians
4. Consumers otherwise called patients
5. Regulatory agencies

It is possible to further characterize each of these groups as "unethical," "predatory," "criminal," and/or "incompetent/careless." These modifiers help narrow the broad brush painted by the first listing.

The group I know best is physicians. Most physicians who contribute to this problem do it unwittingly and/or incompetently, rather than maliciously. Often, the desire to please patients or to retain them as "customers," results in the aiding and abetting of the opioid epidemic.  Resolution to avoid contributing to the problem by pharmacies and physicians will help begin solving this problem.

The following steps will start the stopping of the abuse of opioids:

1. With electronic prescribing, the monitoring of patterns of use of opioids is much easier. All states must immediately require any prescriber of opioids to do so electronically. That will shut down pill mills very quickly.  It will be objected to by providers who are not using electronic records or by providers who are using electronic records but are not e-prescribing controlled substances.  These objections are not legitimate and should be ignored.  If providers decide not to use electronic records and/or electronic prescribing of controlled substances, they should not be allowed to prescribe these drugs.

2. The patients’ medical records must reflect that:

1. Before opioids are prescribed, except for five days following a procedure, that the patient has been tried on non-narcotic pain medication and/or on anti-inflammatory medications. 
2. The potential, and in the case of opioids, the certainty of physician or mental addiction has been discussed with the patient.
3. At least once a year Prescription Access in Texas (PAT) must have been reviewed to see whether a patient is receiving controlled substances from more than one pharmacy or from more than one healthcare provider.

The following is the way SETMA tracks this function in our EMR.



4. A diagnosis or diagnoses is documented which warrants chronic pain medications
5. An effort is made at least once a year to decrease the amount of pain medication being taken or to eliminate its use completely.
6. If pain medication uses is judged to be excessive, that the patient is referred to a pain management specialist. 
7. Documentation of the use of a screening tool for patients who are high risk for abusing pain medications, such as the ‘Screener and Opioid Assessment For Patients with Pain,” which is the tool which SETMA uses.  This was discussed in last week’s article.

3. All providers and pharmacies must be required to audit their own prescribing of opioids. Criteria for alerting potential abuse of opioids should be identified by an expert panel. The following are suggestions for starting that process:

1. Any patient on opioids longer than six months should trigger a requirement for a written review and justification by the provider, the patient and the pharmacy.
2. Any patient taking more than three pain pills in a 24-hour period on a regular schedule.
3. All opioids should be prescribed on an “as needed” or “prn” dosing schedule.  This will not in and of itself stop opioid abuse but it begin to educate providers and patients that pain mediations should be taken only for pain and not for the anticipation of pain or for the prevention of pain.  The surest sign of inappropriate pain medication use is when a patient asks how many pain pills he/she takes in a day and the answer is, “It is prescribed for every four or for every six hours.”

4. All of the following should trigger a review of a patient’s use of opioids:

1. If a patient is taking more than one class or kind of pain medication simultaneously, a review should be triggered.
2. If a patient is obtaining pain mediation from multiple providers, or from multiple pharmacies, a review should be triggered.
3. Providers or pharmacies who prescribe or refill opioids for patients receiving them from multiple providers and/or from multiple pharmacies should lose their prescribing or dispensing privileges for one year for the first offense and permanently for the second.

If it is thought that these are draconian measures, it is consistent with the seriousness and severity of the problem.  Administratively, this will be a night mare, but it would immediately be effective and it puts responsibility, functionally, where it will count.  Also, these measures may seem intrusive but the crisis warrants such measures.