Marissa Seligman, PharmD, is chief clinical and regulatory affairs and compliance officer and senior vice president for Pri-Med Institute of pmiCME. PmiCME is the accredited education division of DBC Pri-Med. Dr. Seligman has more than 20 years experience in healthcare and continuing education. Here Dr. Seligman discusses challenges and education efforts regarding physician opioid dosing and prescribing.
Question: What are the current concerns regarding physician dosing and prescribing of opioids?
Dr. Marissa Seligman: At the center of current concern is the number of overdoses and unintentional deaths associated with the non-medical use of opioids for non-cancer pain, which has steadily soared since the 1990s. For example, recent data shows between 2009 and 2010 almost one million people 12 years and older reported non-medical use of opioids for 200 days or more, and more than four million people reported such use for 30 days or more. Additionally, in 2009 there were almost 425,000 emergency department visits involving non-medical use of opioids and 15,597 deaths. Factors that have been identified as increasing the risk of opioid overdose-related deaths include higher opioid doses, male sex, greater age, overlapping opioid and sedative/hypnotic prescriptions, and increased number of prescriptions, particularly extended-release and long-acting opioid products, lack of awareness and understanding by prescribers and dispensing pharmacies.
The gaps between the guideline recommendations for safe prescribing practices of extended-release and long-acting opioids and current performance of primary care clinicians in particular, are due in part to overall inadequate training in pain medicine. To deliver better outcomes for patients, physicians and other healthcare providers who prescribe ER-and LA-opioids need better training on when and how long to prescribe these medications.
Q: What steps are being taken to address these concerns?
MS: There are a number of steps being taken by healthcare provider associations, patient advocacy groups, state and federal governments to curb misuse and promote safer patient care and by accredited providers of continuing education for healthcare providers to conduct training and education programs for prescribers of ER/LA-opioids.
Specifically, in July 2012, the FDA took an important and new step to address the concern by issuing a Risk Evaluation and Mitigation Strategy for ER and LA opioids by including, among many safety measures, a mandate that manufacturers of ER/LA opioid analgesics (there are about 20 of affected) fund accredited continuing medical education activities that will be made available to prescribers of ER/LA opioids. Each CME activity must be created and implemented based on an FDA Blueprint for prescriber education. To provide these education programs to the medical community, the group of manufactures, called the REMS Program Companies, created a process whereby accredited CME providers can submit for grants from the PRC.
Q: What type of education should physicians undergo to safely prescribe opioids? Is this training limited to pain management physicians?
MS: First, it is important to note that primary care clinicians, including internists, general medicine physicians, family physicians, osteopathic physicians, nurse practitioners and physician assistants, play a critical role in delivering effective pain management, including the prescribing of opioids. The U.S. uses 75 percent of all prescription opioids in the world, according to recent studies. In fact, primary care clinicians comprise the largest group of ER/LA prescribers at 54 percent.
As practitioners on the frontline of care, PCPs are in the best position to become a key part of the solution to address the current epidemic of opioid overdoses and deaths by undergoing in-depth and clinically-relevant training on current evidence-based guidelines for prescribing opioids, which cover how to appropriately screen patients, manage dosage, monitor use, as well as communicating and working with their patients to reduce the abuse and dangers associated with ER/LA-opioid use. ER/LA prescribers can also benefit from learning about addiction and how to assess the risk of abuse, as well as side-effects and drug-drug interactions. Clinician barriers to effective opioid prescribing include a fear of causing harm due to side effects to patients (reported by 77 percent of clinicians in a Pri-Med survey of 26 PCPs).
A survey of Pri-Med PCP learners from several regions of the U.S. on ER/LA opioid prescribing practices was conducted in 2011. In response to the question "How frequently do you use a written screening tool to assess risk for opioid misuse?" 61 percent answered "never" and only 15 percent said "always," with 12 percent indicating they assess for misuse "most of the time." Interestingly, 9 percent of responders indicated they used risk assessment tools "only in patients who strike me as potential opioid abusers." With best-practices education, prescribers can feel more confident that the treatment strategy they put in place is what is best for the patient and work with them to achieve shared management outcomes goals while reducing the risk of abuse, addition and death due to overdose.
Q: How can clinician prescribers better determine who may or may not be a good candidate for prescription opioids?
MS: There are published screening mechanisms and tools in place to help clinicians assess whether a patient is an appropriate candidate for opioid therapy. Prescribers of ER/LA opioids should seek out tools from licensed accredited providers including risk assessment questionnaires, samples of opioid agreements and ACCME-compliant CME programs on ER/LA opioids. Effective screening and patient assessments are critical to safe prescribing.
Q: What progress has been made in the last few years in regard to physician opioid training?
MS: The good news is, thanks to the rise in online learning, physicians now have more ready access to resources and education on opioids and pain management strategies, as well as support from other clinicians and leaders in the field. Due to the availability of interactive technologies online, physicians can now compare how they do in post-tests against their peers, which has not always been possible.
Q: What challenges remain?
MS: A considerable amount of education is still needed to close the gaps in patient care relative to non-cancer pain and ER/LA opioid prescribing. We should also see more emphasis placed on pain management in medical school and residency. For example, in a survey by O'Rorke and colleagues of community and university-based PCPs in internal medicine, family practice, and internal medicine residency programs in which 572 physicians completed an 84-item questionnaire, 24 percent to 32 percent of the respondents reported receiving "limited" education in pain management during medical school, residency and thereafter; 45 percent to 55 percent received "in depth" education, while about 20 percent received no education in pain management whatsoever during their training.
The PCPs who received education in chronic pain management were more comfortable in caring for patients with chronic pain; this increased level of comfort was correlated with training after residency. The authors concluded that training in pain management should be a key component of Internal Medicine and Family Medicine continuing medical education curricula.
More Articles on Pain Management:
Michigan Group Introduces Pain Management Program at YMCA
Study: Multidisciplinary Teams May Improve Outcomes for Chronic Pain Patients
Primary, Mobility & Injury Specialists Joins Florida Pain Network
Question: What are the current concerns regarding physician dosing and prescribing of opioids?
Dr. Marissa Seligman: At the center of current concern is the number of overdoses and unintentional deaths associated with the non-medical use of opioids for non-cancer pain, which has steadily soared since the 1990s. For example, recent data shows between 2009 and 2010 almost one million people 12 years and older reported non-medical use of opioids for 200 days or more, and more than four million people reported such use for 30 days or more. Additionally, in 2009 there were almost 425,000 emergency department visits involving non-medical use of opioids and 15,597 deaths. Factors that have been identified as increasing the risk of opioid overdose-related deaths include higher opioid doses, male sex, greater age, overlapping opioid and sedative/hypnotic prescriptions, and increased number of prescriptions, particularly extended-release and long-acting opioid products, lack of awareness and understanding by prescribers and dispensing pharmacies.
The gaps between the guideline recommendations for safe prescribing practices of extended-release and long-acting opioids and current performance of primary care clinicians in particular, are due in part to overall inadequate training in pain medicine. To deliver better outcomes for patients, physicians and other healthcare providers who prescribe ER-and LA-opioids need better training on when and how long to prescribe these medications.
Q: What steps are being taken to address these concerns?
MS: There are a number of steps being taken by healthcare provider associations, patient advocacy groups, state and federal governments to curb misuse and promote safer patient care and by accredited providers of continuing education for healthcare providers to conduct training and education programs for prescribers of ER/LA-opioids.
Specifically, in July 2012, the FDA took an important and new step to address the concern by issuing a Risk Evaluation and Mitigation Strategy for ER and LA opioids by including, among many safety measures, a mandate that manufacturers of ER/LA opioid analgesics (there are about 20 of affected) fund accredited continuing medical education activities that will be made available to prescribers of ER/LA opioids. Each CME activity must be created and implemented based on an FDA Blueprint for prescriber education. To provide these education programs to the medical community, the group of manufactures, called the REMS Program Companies, created a process whereby accredited CME providers can submit for grants from the PRC.
Q: What type of education should physicians undergo to safely prescribe opioids? Is this training limited to pain management physicians?
MS: First, it is important to note that primary care clinicians, including internists, general medicine physicians, family physicians, osteopathic physicians, nurse practitioners and physician assistants, play a critical role in delivering effective pain management, including the prescribing of opioids. The U.S. uses 75 percent of all prescription opioids in the world, according to recent studies. In fact, primary care clinicians comprise the largest group of ER/LA prescribers at 54 percent.
As practitioners on the frontline of care, PCPs are in the best position to become a key part of the solution to address the current epidemic of opioid overdoses and deaths by undergoing in-depth and clinically-relevant training on current evidence-based guidelines for prescribing opioids, which cover how to appropriately screen patients, manage dosage, monitor use, as well as communicating and working with their patients to reduce the abuse and dangers associated with ER/LA-opioid use. ER/LA prescribers can also benefit from learning about addiction and how to assess the risk of abuse, as well as side-effects and drug-drug interactions. Clinician barriers to effective opioid prescribing include a fear of causing harm due to side effects to patients (reported by 77 percent of clinicians in a Pri-Med survey of 26 PCPs).
A survey of Pri-Med PCP learners from several regions of the U.S. on ER/LA opioid prescribing practices was conducted in 2011. In response to the question "How frequently do you use a written screening tool to assess risk for opioid misuse?" 61 percent answered "never" and only 15 percent said "always," with 12 percent indicating they assess for misuse "most of the time." Interestingly, 9 percent of responders indicated they used risk assessment tools "only in patients who strike me as potential opioid abusers." With best-practices education, prescribers can feel more confident that the treatment strategy they put in place is what is best for the patient and work with them to achieve shared management outcomes goals while reducing the risk of abuse, addition and death due to overdose.
Q: How can clinician prescribers better determine who may or may not be a good candidate for prescription opioids?
MS: There are published screening mechanisms and tools in place to help clinicians assess whether a patient is an appropriate candidate for opioid therapy. Prescribers of ER/LA opioids should seek out tools from licensed accredited providers including risk assessment questionnaires, samples of opioid agreements and ACCME-compliant CME programs on ER/LA opioids. Effective screening and patient assessments are critical to safe prescribing.
Q: What progress has been made in the last few years in regard to physician opioid training?
MS: The good news is, thanks to the rise in online learning, physicians now have more ready access to resources and education on opioids and pain management strategies, as well as support from other clinicians and leaders in the field. Due to the availability of interactive technologies online, physicians can now compare how they do in post-tests against their peers, which has not always been possible.
Q: What challenges remain?
MS: A considerable amount of education is still needed to close the gaps in patient care relative to non-cancer pain and ER/LA opioid prescribing. We should also see more emphasis placed on pain management in medical school and residency. For example, in a survey by O'Rorke and colleagues of community and university-based PCPs in internal medicine, family practice, and internal medicine residency programs in which 572 physicians completed an 84-item questionnaire, 24 percent to 32 percent of the respondents reported receiving "limited" education in pain management during medical school, residency and thereafter; 45 percent to 55 percent received "in depth" education, while about 20 percent received no education in pain management whatsoever during their training.
The PCPs who received education in chronic pain management were more comfortable in caring for patients with chronic pain; this increased level of comfort was correlated with training after residency. The authors concluded that training in pain management should be a key component of Internal Medicine and Family Medicine continuing medical education curricula.
More Articles on Pain Management:
Michigan Group Introduces Pain Management Program at YMCA
Study: Multidisciplinary Teams May Improve Outcomes for Chronic Pain Patients
Primary, Mobility & Injury Specialists Joins Florida Pain Network