Editor’s note: The complexities of the opioid epidemic demand a comprehensive approach response. This practice perspective provides physician insights into one course of action that could contribute to the solution.
By Joan Papp, MD, Case Western Reserve University and Metro Health Medical Center in Cleveland, and Jason Jerry, MD, Cleveland Clinic Foundation
Pain management and the opioid epidemic
The United States is confronting a tragic opioid epidemic—and the situation is getting worse. More American lives were lost in 2014 from drug overdose than during any previous year on record. According to the most recent data from the Centers for Disease Control and Prevention, the drug overdose death rate from opioids increased by 200 percent between the years 2000 and 2014. To put this in perspective, during the 10-year period spanning 2004-2013, a total of 181,000 people in this country lost their lives to prescription pain medication or heroin overdoses.
In the treatment world, we tend to view prescription narcotics and heroin as sides of the same coin because they affect the brain in the same way. In working with patients who are addicted to heroin, we have noted that our patients most often report developing an addiction to prescription narcotics before transitioning to heroin.
The motivation to switch from pain relievers to heroin is often driven by economics, as heroin is about 10 percent of the cost of an equivalent dose of a prescription narcotic. Armed with this knowledge and the fact that the United States consumes 75 percent of the world’s narcotic pain medication—despite only comprising 5 percent of the world’s population—it would be easy for people to blame the doctors for our narcotic woes.
It wasn’t until the mid-1990s that doctors began writing prescriptions for narcotics to manage chronic musculoskeletal pain. Previously, narcotics were largely reserved for treating the pain associated with surgery and end-stage cancer.
But then the culture of medical practice surrounding pain management changed drastically. There was a perception that doctors were undertreating pain, and the development of the “fifth vital sign”—the 10-point pain scale—was added to the medical charts of hospitals throughout the country. That meant that doctors had to address pain as a critical function of care.
Patient satisfaction surveys
Fast forward two decades, and patient satisfaction surveys became an integral part of Medicare and Medicaid payments to hospitals. Many of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions inquire about important metrics, such as communication between doctors and their patients.
Consider, however, the following questions pertaining to pain management taken from the HCAHPS questionnaire: (1) “During this hospital stay, did you need medicine for pain?” Patients can answer “yes” or “no.” (2) “During this hospital stay, how often was your pain well controlled?” Patients can answer “never,” “sometimes,” “usually” or “always.” (3) “During this hospital stay, how often did hospital staff do everything they could to help you with your pain?” Patients can answer “never,” “sometimes,” “usually” or “always.”
It is easy to see how problematic this can be.
First: When it comes to reimbursement for the current HCAHPS questions, the Centers for Medicare & Medicaid Services (CMS) doesn’t give partial credit. This means that unless the patient answers “always” to questions 2 and 3, the hospital is considered an underperformer and is financially penalized. The simplest way for physicians to improve their scores, then, is to be more liberal with opioid pain medications.
Second: There are no questions asking if other pain control options, such as ice packs, improved positioning, physical therapy or surgical interventions were discussed, which undervalues the discretion of the doctor and the integrity of the doctor-patient relationship.
Third: The questions do not describe other unpleasant states that a patient may experience. If we exchanged the word “pain” for “discomfort,” the question would encompass a far more comprehensive patient experience that would include other uncomfortable sensations, such as itching or burning.
If we were to make these simple changes, we would be able to more broadly evaluate how we treat pain and take the focus off of receiving only opiates.
Pressure to overprescribe
We are not alone in feeling the pressures of this misguided policy. Recently, the Ohio State Medical Association (OSMA), in partnership with the Cleveland Clinic Foundation, surveyed 1,100 Ohio physicians. In this survey, 98 percent of the physicians who participated reported that they felt increased pressure to treat pain, and 74 percent reported that they felt an increased pressure to prescribe opioids because of the perverse pain management incentives in the patient satisfaction surveys.
An additional 67 percent of respondents agreed that, in general, physicians in the United States over-prescribe controlled substances to treat pain. One physician stated: “I have faced consequences from my hospital for not prescribing narcotics even if [the] patient had a huge, multi-page [Ohio Automated Rx Reporting System] report.” In fact, 24 percent of physician respondents indicated that asking patients about pain control might have the unintended consequence of driving opioid addiction.
What we can do
Clearly, the cultural paradigm of overly aggressive pain management still exists and will continue to be a barrier to efforts to address the opioid epidemic.
Here in Ohio, we’re advocating for the adoption of a resolution under consideration by our state legislature. This resolution would both call on CMS to revise the HCAHPS survey measures to better address the topic of pain management and support drug abuse research, education, community outreach and prevention. Both the OSMA and the AMA have officially supported this measure.
On a national level, it is time for all physicians to let CMS know our concerns and demand that the pain questions be revised in HCAHPS and other future patient satisfaction surveys. Our patients’ lives hang in the balance.