EXECUTIVE SUMMARY
The Centers for Disease Control and Prevention (CDC) issued new guidelines for prescribing and managing prescription opioids in hopes of curtailing some of the nation’s more than 14,000 opioid overdose deaths each year.
- CDC recommends more cautious opioid prescribing and more consistent and informed monitoring of patients who are using these drugs.
- Case managers can educate patients about the risks of prescription opioids and give them information about alternative pain management solutions.
- Case managers also can identify community resources for patients who have been using prescription opioids and either have an addiction issue or need to find alternatives to opioids.
Case managers, like other healthcare professionals, have seen firsthand the damage caused by prescription opioid abuse. The new opioid prescription guidelines from the Centers for Disease Control and Prevention (CDC) are a welcome change, some case managers say.
“This is the first time the federal government is stepping up with a stronger message and actually saying what states and physicians need to be doing to stop this [opioid] runaway train,” says Kathleen Fraser, RN-BC, MSN, MHA, CCM, CRRN, national president of the Case Management Society of America (CMSA).
“I think everybody has acknowledged that there is a problem, and we need more stringent guidelines,” says Cheri Bankston, RN, MSN, director of clinical advisory services at Curaspan Health Group in Newton, MA.
The CDC’s new recommendations push for more cautious opioid prescribing and more consistent and informed monitoring of patients using the drugs. Released in March 2016, the CDC’s guidelines are in response to what the federal agency calls an epidemic of prescription opioid overdoses. One out of five patients who have non-cancer pain symptoms is prescribed opioids. This is one of the reasons why opioid prescriptions and sales have quadrupled since 1999.1
Now there are more than 14,000 Americans dying — about 40 per day — from overdoses of the prescription drug, says CDC Director Tom Frieden, MD, MPH. (See the CDC’s recommendations in this issue.)
Chiefly, the guidelines are for primary care physicians who prescribe opioids for chronic pain that is not related to active cancer treatment, palliative care, or end-of-life care. This same population often has chronic conditions that result in their receiving case management services.
“One of the problems we’ve seen — and the CDC brought out a lot of this with the release of the guidelines — is the sheer volume of people who are using or dependent on prescription opioids: Nearly 2 million Americans either were dependent or abused opioids in 2014,” Bankston says.
In 2012, more than half a million emergency department visits were due to people misusing or abusing prescription pain killers, and these visits were by people who used emergency rooms in hopes of getting more pain medication, Fraser notes.
“From a case management perspective, we deal with the downstream effect of opioid abuse,” Bankston says. “I think these guidelines will help support what we’ve been doing all along, including directing patients to the best therapy and avoiding any side effects or long-term negative impact of therapy that leads to an abuse or addictive situation.”
Physicians can use the guidelines to inform their opioid prescribing policies, but the CDC’s paper also provides an additional tool for case managers when they wish to educate patients about opioid use risks.
“Case managers can educate patients about the statistics and death rates from accidental overdoses of these prescription medications and the dangers of being on them daily for a very long period of time,” Fraser says.
In workers’ compensation cases, case managers should consider statistics showing that injured employees who start taking short-term prescription opioids have three times the claim costs — from $13,000 to $39,000 — as workers who are prescribed over-the-counter pain medications, Fraser says.
“Yet when that same employee is prescribed a long-acting opioid, the claim costs explode to $117,000,” Fraser adds.
Case managers also should consider quality-of-life issues faced by patients who use opioids for chronic pain, Fraser says.
“We are patient advocates, and you are not a patient advocate if you don’t address this issue,” Fraser says.
For example, case managers can educate patients about pain therapies that do not involve opioids.
“We can be experts and resources for our patients about other pain therapies that might be appropriate or prescribed when the physician is moving away from opioids,” Bankston says. “We need to be aware of pain therapy, physical therapy, counseling, and other medication therapies other than opioids.”
The CDC’s guidelines highlight the importance of medication reconciliation. “Medication reconciliation is something we do every time we encounter a patient, whether in the home, community, or acute care setting at the hospital,” Bankston says. “We want to make sure we have a clear picture of what kind of medication the patient has, which prescribers are involved, and reconciling these before we transition the patient to another setting.”
One way providers can make certain patients are not abusing opioids through using different prescribers and pharmacies is to access state prescription drug monitoring program (PDMP) data, Bankston says.
A PDMP is a statewide electronic database that can be used to identify and prevent drug abuse and diversion.
“A lot of times, what we run into is there are multiple prescribers,” Bankston explains. “A patient might use multiple pharmacies, and this could lead to a lot of problems with miscommunication and overprescribing.”
Using the PDMP is a way providers and institutions can gain a clearer picture of what’s going on with a patient’s opioid use, she adds.
Case managers also can assist with monitoring patients who are prescribed opioids to make sure they are benefiting from the drug, including having improved pain and function, Bankston says.
“At the same time, case managers need to be prepared and make sure they understand the guidelines, recognize problems, and focus on medication reconciliation,” Bankston says.
As physicians begin to change opioid prescribing habits in response to the CDC guidelines and media attention on the issue of prescription opioid abuse and overdoses, case managers have another helpful role to play: “We understand the community resources available to the patient,” Bankston says.
“So we need to make sure when we’re looking at those resources that we’re considering those that might be able to meet the needs of the patient, whether that’s a substance abuse program or a mental health provider or a pain management clinic,” she explains. “We need to have easy availability and connectivity to those providers so we can give patients choices and so that we know in advance which providers can meet those patients’ needs.”
REFERENCE
- Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR. 2016;65(1):1-49.