MGMA outlines 3 key components of opioid prescribing policies

A new report released by the Medical Group Management Association has pinpointed three major focus areas that medical practices can use to reduce opioid prescribing and the risk of misuse, as well as key principles that all medical practices can follow to develop or modify successful and effective opioid prescription policies.

"The opioid epidemic has become an unprecedented crisis in the United States and, as such, Americans need to come together to develop comprehensive solutions -- at all levels," said Halee Fischer-Wright, president and CEO of MGMA. "Our goal with this report was to find the best ways in which medical practices and healthcare providers -- those on the frontlines -- can drive meaningful parts of solving this crisis."

According to the Centers for Disease Control and Prevention, 115 Americans die each day from an opioid-related overdose, fueling a trend that has positioned these drug overdoses as the leading cause of death for Americans under 50, the report said. The cost of the opioid epidemic to hospitals is estimated at about $216 billion from 2001 to 2017, due largely to overdose-related emergency room visits, according to an Altarum report published earlier this year.

A Recent MGMA Stat poll showed that 83 percent of medical practices have tightened opioid prescribing protocols for patients and 61 percent of practices that do prescribe opioids educate patients on potential misuse. 

To that end, in its new report MGMA identified three areas that will define success for an effective opioid prescription policy.

First, communication is essential between any and all parties that are involved in prescribing opioids within the practice. That means patients, staff, providers and pharmacists too. These stakeholders must make sure all those involved are fully aware of what constitutes proper opioid use and how to identify misuse.Engaging as many relevant team members as possible in the process can help alleviate differences and foster buy-in for a new or modified opioid policy, as can monthly meetings of these stakeholders. The report also mentioned that keeping track of each provider's prescribing levels can be helpful in addressing differing practices and addressing concerns, although some contributors also mentioned that their current practice management systems  can make managing such data and addressing variances challenging. In this area, practice leaders said regular scheduling of of physician and/or clinical staff meetings to review prescribing rates and patient population issues is a recommended solution.

Communication with patients is also a must. Multiple practice leaders recommend and have themselves adopted a policy of having patients that are starting treatment for chronic pain with an opioid sign a patient agreement for controlled substances that spells out expectations for safe use and storage of their medication, requires the patient to obtain their medication from a single designated prescriber and single pharmacy, requires periodic drug testing, asks them to attest that they will not use alcohol or drugs during their treatment, and outlines the process for terminating the patient from the practice for noncompliance. Having the right bedside manner and discussing issues at a pace that is comfortable for the patient also goes a long way.

Second, the use of technology is key to tracking prescriptions. Practices that employ prescription drug monitoring programs, or PDMPs, can better identify those patients who've gotten opioids from other providers, signaling potential misuse or at least cause for a conversation with that patient.

Figuring out how to integrate the use of a PDMP with a practice's EHR is a barrier for many organizations, and the report argued that PDMP is only as good as the information it provides, increasing the call for a national PDMP as some practices service patients from neighboring states. Developing workarounds for this issue is key. Checking their own state's PDMP is the necessary first step and evaluating where they send patients from neighboring states will support these efforts. One practice leader has a group located in Maryland but sees patients from Virginia too. When the providers treat a Virginia patient, they send them to a pharmacy in that state for their medications. Luckily, Maryland's PDMP contains data from other nearby states such as Virginia, West Virginia, D.C., Pennsylvania and others. But keeping those lines of separation clear may help keep patient medication use information more accurate.

Also, using electronic prescriptions can help stop fake prescriptions from being filled, the report said.

A third focus area is referral management. Primary care providers who send patients to specialty practices for long-term pain management must have a clear understanding of the pain specialists in the area and their capabilities and policies. Establishing good relationships with area specialists is important and a good first step should include having those providers visit the PC practice to provide education on how they approach pain management with their patients. 

MGMA also developed standards that should guide medical practices in developing or modifying an opioid prescription policy. First, opioids should not be the first line of treatment for chronic pain. Should opioids be deemed the best course of action for a patient, then they should be combined with nonpharmacologic therapy and/or nonopioid pharmacologic therapy, as appropriate.

Second, all opioid treatment plans include when and how opioid therapy will eventually be discontinued as patients complete treatment. Education and evaluation are crucial, including the philosophy that "there is never a bad time to address the risks of opioid misuse with the patient, whether before beginning therapy or while managing therapy." An evaluation of the benefits and harms of opioid use should happen between one and four weeks after opioid therapy begins and after any dosage increase.

The proper dose and length of use should always be employed. "Immediate-release opioids at the lowest effective dosage are preferred for starting therapy, prescribed in a quantity no greater than what is required for the duration of pain that is severe enough to require opioids," the report said.

PDMP data should be used to evaluate patients before starting them on opioid therapy and should also occur periodically thereafter, and urine drug testing of patients should happen at the start of opioid therapy, with subsequent testing occurring at least once a year.

Finally, have a plan for handling patients with opioid use disorder and be ready to offer options or to arrange treatment.

"By arming practice leaders and healthcare providers with this information, we're hopeful that they can be even more effective in fighting this epidemic at one of the most critical junctures: the point of care," Fischer-Wright said.

Twitter: @BethJSanborn
Email the writer: beth.sanborn@himssmedia.com