Clinician Education on Prescribing Practices

According to the Centers for Disease Control and Prevention, there is much variability on the prescribing practices across the nation. The amount of opioids prescribed per person was three times higher in 2015 than in 1999. This translates to enough opioids to medicate every American around the clock for three weeks. By appropriately prescribing opioids and offering alternative pain management options or both, practitioners have the ability to limit potential long-term use, prevent opioid use disorder, and decrease opioids available for illegal theft and resale in the community. Hospitals are educating their clinicians in a variety of ways—for example, through medical staff meetings, online CME, grand rounds and benchmarking—and sharing data with clinicians about their prescribing practices compared to others. The National Academy of Medicine emphasizes the importance of providing clinician education on appropriate prescribing practices and on recognizing and treating substance use disorder. These resources support those efforts.

• State Prescription Drug Monitoring Programs (June 2016). The U.S. department of Justice’s Drug Enforcement Administration (DEA) created a webpage with resources about the Prescription Drug Monitoring Programs (PDMP). It explains what it is, the benefits of using it, which states have a PDMP, who can access the PDMP information, among many other topics.
• Managing the Nation's Pain: NQF Issues Essential Guidance on Opioid Stewardship (2018). The National Quality Forum released a playbook for providers to use as a guide to implement and sustain an opioid stewardship program. The 43-page report offers seven steps for healthcare organizations to curb inappropriate opioid usage and strategies to complete those steps. The playbook aligns with NQF's announcement last July of an opioid stewardship program focused on lower rates of overprescribing for pain.
• Pain and Symptom Management for People with Serious Illness in the Context of the Opioid Epidemic, Washington, DC (November 29, 2018). The Roundtable on Quality Care for People with Serious Illness hosted a workshop to explore the tension between efforts to address the opioid epidemic and the resulting impact on access to pain medications for people facing serious illness. The workshop examined the unintended consequences of the responses to the opioid epidemic for patients, families, communities, and clinicians; and potential policy opportunities to address them.

Acute Pain

• Association of Lowering Default Pill Counts in Electronic Medical Record Systems with Postoperative Opioid Prescribing (June 2018). Reliance on prescription opioids for postprocedural analgesia has contributed to the opioid epidemic. With the implementation of electronic medical record (EMR) systems, there has been increasing use of computerized order entry systems for medication prescriptions, which is now more common than handwritten prescriptions. The EMR can autopopulate a default number of pills prescribed, and 1 potential method to alter prescriber behavior is to change the default number presented via the EMR system.
• Safe Opioid Prescribing in the State of Illinois. The Illinois Department of Public Health and The Illinois Office of the Attorney General recognize the importance of prescriber education in patient care and safety. To address the opioid crisis in Illinois we have partnered to offer an educational toolkit for new prescribers to the state. This module consists of a 15-minute video with best practices in opioid prescribing and an introduction to the Illinois prescription drug monitoring program.
• Emergency Department Contribution to the Prescription Opioid Epidemic (Dec 2017) This study in the Annals of Emergency Medicine examines examine whether higher-risk opioid users receive a disproportionate quantity of their opioids from ED settings. The conclusion states “further efforts to reduce the quantity of opioids prescribed may have limited effect in the ED and should focus on office-based settings.”
• Inpatient Opioid Misuse Prevention (June 2018). These clinical practice guidelines are an educational aid for providers on prevention of opioid misuse.
• American College of Emergency Physicians’ Clinical Policy on Opioid Prescribing. (2012) This resource provides an overview for prescribing opioids to adults in the emergency department. It presents three levels of recommendations for critical issues based on: generally accepted principles for patient management, recommendations for patient management, and recommendations based on a panel consensus.
• Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder. (2017) This resource seeks to standardize humane, evidence-based care of patients with opioid use disorder in the state’s emergency and hospital institutions.
• Opioid Prescribing: Where you live matters. (2017) The Centers for Disease Control and Prevention recommends that for acute pain, prescriptions should only be for the expected duration of pain severe enough to need opioids. CDC experts say three days or less is often enough; more than seven days is rarely needed. (See page three of linked document.) The CDC also created a checklist for prescribing opioids and a dosing calculation fact sheet.
• A report by the National Academies of Sciences, Engineering, and Medicine noted that “[t]here do not appear to be any widely accepted guidelines for postoperative prescribing.” However, the report highlighted the following studies:
  • An evaluation of postoperative opioid consumption, finding that patients are being prescribed approximately three times greater opioid medications than needed following upper-extremity surgical procedures. The authors provide general prescribing guidelines. (2016)
  • A retrospective review finding that an opioid prescribing guideline significantly decreased the rates at which opioids were prescribed for minor and chronic complaints in an acute care setting. (2016)
• American Dental Association Recommendations. (2017) This resource is a formal ADA Statement on the Use of Opioids in the Treatment of Dental Pain, adopted by the ADA House of Delegates in October 2016.
• Improving Pain Management for Hospitalized Patients. (n.d.) This guide provides practical advice to hospitalists and other leaders who are developing programs to improve pain management in their services and facilities. The focus is on medical patients, though many of the principles described here are relevant to patients recovering from surgical care who are increasingly co-managed by hospitalists. The content on best practices in pain management is drawn from a multidisciplinary national expert panel.
• Substance Use Disorder Prevention & Treatment (n.d.) The Substance Use Disorder Prevention and Treatment Task Force was developed at the direction of the Massachusetts Health & Hospital Association’s board of trustees to develop provider-focused strategies to help address the high incidence of opioid misuse in the community. This web page provides links to several resources, including Guidelines for Opioid Management by Clinicians and Staff within a Hospital Setting.

Chronic Pain

• CDC’s Quality Improvement and Care Coordination Resource (2016). The Centers for Disease Control and Prevention's (CDC) National Center for Injury Prevention and Control has developed and released the Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain. The purpose of the resource is to encourage careful and selective use of long-term opioid therapy in the context of managing chronic pain through evidence-based prescribing, quality improvement (QI) measures to advance the integration of the guideline into clinical practice, practice-level strategies to improve care coordination; and a resource toolkit.
• Office of Disease Prevention and Health Promotion – Pathways to Safer Opioid Use. The Pathways to Safer Opioid Use, created by the Office of Disease Prevention and Health Promotion (ODPHP), is an interactive training that promotes the appropriate, safe, and effective use of opioids to manage chronic pain. It’s based on the opioid-related recommendations in the National Action Plan for Adverse Drug Event Prevention.
• Dosing and Titrating Opioids (Aug 2016). Evidence indicates that the risk for opioid-use disorder and overdose increases as dosage increases. CDC Guideline for Prescribing Opioids for Chronic Pain provides recommendations about the types of opioid formulations at initiation, starting dosages, morphine milligram equivalent dosage calculation methods, dose titrating considerations, and tapering methods. During this COCA Call, clinicians will learn about the association between opioid dosage and opioid therapy benefits and harms. In addition, presenters will use a case study of a patient with severe back pain on oxycodone to guide clinicians through safe opioid prescribing practices.
• The Invisible Crisis: Understanding Pain Management in Medicare Beneficiaries with Sickle Cell Disease (Sept 2018). This resource created by the Centers for Medicare and Medicaid (CMS) describes opioid utilization patterns and the characteristics of Medicare fee-for-service beneficiaries with and without Sickle Cell Disease, based on Medicare Part D prescription drug records.
• Guidelines for the Chronic Use of Opioid Analgesics. (2017) This document has been adopted as policy by the Federation of State Medical Boards. This policy document includes relevant recommendations, and is in keeping with recent releases of advisories issued by the CDC and FDA. This policy is intended as a resource providing overall guidance to state medical and osteopathic boards in assessing physicians’ management of pain in their patients and whether opioid analgesics are used in a medically appropriate manner.
• CDC Guideline for Prescribing Opioids for Chronic Pain. (2016) This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care and end-of-life care.
• Guideline Resources: CDC Opioid Guideline Mobile App. (2016) CDC’s Opioid Guideline App is designed to help providers apply the recommendations of CDC’s Guideline for Prescribing Opioids for Chronic Pain into clinical practice by putting the entire guideline, tools, and resources in the palm of their hand.
• VA Management of Opioid Therapy for Chronic Pain. (2017) This guideline describes the critical decision points in the management of opioid therapy for chronic pain and provides clear and comprehensive evidence-based recommendations incorporating current information and practices for practitioners throughout the Department of Defense and VA health care systems. The workgroup consensus statements are provided to minimize harm and increase patient safety in patients requiring opioid therapy.
• CDC's Guideline Resources: Posters. (August 2017). The Guideline for Prescribing Opioid for Chronic Pain is intended to help primary care providers determine when and how to prescribe opioids for chronic pain, and it equips providers with the information they need to discuss chronic pain treatment with their patients. The posters below can help patients and providers work together to manage pain effectively and safely.

Clinician Trainings, Simulations, and Other Resources

• Prescription Drug Monitoring Program Laws and Rules. This webpage houses links to all prescription drug monitoring programs by state. It includes links to websites on laws and regulation/rules. A subpage includes PDMP Policies and Procedures, Technology, PDMMP Requestors, and Types of available reports.
• Applying CDC’s Guideline for Prescribing Opioids. (2017) This interactive, web-based training features self-paced learning, case-based content, knowledge checks and integrated resources to help health care providers gain a deeper understanding of the Practice Guideline. Includes tips on implementing the Guideline into primary care practice and overcoming challenges. Earn free CE credit.
• Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals. (2017) The Joint Commission’s announcement of the implementation of new and revised pain assessment and management standards, effective January 1, 2018, for its accredited hospitals
• Substance Use Trainings. (2017) The Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration’s (SAMHSA-HRSA) Center for Integrated Health Solutions compiled a repository of resources including online trainings, webinars, live classes, in-person meetings and symposiums about substance use that are available to health care professionals.
• Providers’ Clinical Support System for Opioid Therapies: Education and Training. PCSS is a collaborative project led by the American Academy of Addiction Psychiatry with a coalition of national professional organizations that provides educational trainings and resources to prescribers and providers. Clinical support is provided through online modules, webinars, archived webinars and the PCSS-O mentoring program
• A Primer on the Opioid Morbidity and Mortality Crisis: What Every Prescriber Should Know. (n.d.) The American Medical Association has created this e-learning module that incorporates animation, infographics, and storytelling to raise physician awareness about prescription opioid-related morbidity and mortality, factors influencing opioid-related harm, and what steps can be taken to promote the safe use of this important class of medications.
• CO*RE. (n.d.) CO*RE is a member-led healthcare professional organization that collectively represents 750,000 clinicians. This group has compiled a host of resources including live courses, online courses, state-specific information and other tools.
• Continuing Medical Education (CME) Finder. (n.d.) This online search tool for healthcare professionals lists accredited CE activities that are compliant with the FDA’s Opioid Risk Evaluation and Mitigation Strategy (REMS).
• CDC’s Morbidity and Mortality Weekly Report (MMWR) – on Opioids (March 2018). This article from the CDC provides an overview on the overdose deaths involving opioids, cocaine, and psychostimulants in the United States from 2015–2016.
• SAMHSA Reports and Detailed Tables From the 2016 National Survey on Drug Use and Health (NSDUH) (September 2017). Find reports and detailed tables that present findings and data based on results of the 2016 National Survey on Drug Use and Health (NSDUH).
• Opioid Overdose Prevention Toolkit (2016). This toolkit from SAMHSA offers strategies to health care providers, communities, and local governments for developing practices and policies to help prevent opioid-related overdoses and deaths. Access reports for community members, prescribers, patients and families, and those recovering from opioid overdose.
• Annals of Surgery: Special Series: The Opioid Crisis (2017). This webpage houses multiple resources on a variety of opioid-related topics such as, using electronic prescriptions for opioids and potential culture changes in surgery
• Clinical Pharmacist Chronic Pain Services: Implementing Interprofessional Care (March 2016): Webinar from the AHA’s Physician Leadership Forum and American Society of Health-System Pharmacists describing a clinical pharmacy service that supports the management of chronic pain patients and the benefits these services provide to hospitals and health systems – including the challenges providers face in managing substance abuse.

Risk Evaluation and Mitigation Strategy (REMS)

• Risk Evaluation and Mitigation Strategy (2017). A Risk Evaluation and Mitigation Strategy (REMS) is a strategy to manage known or potential serious risks associated with a drug product and is required by the Food and Drug Administration to ensure that the benefits of a drug outweigh its risks. The FDA has required a REMS for extended-release and long-acting opioid analgesics.
• Risk Evaluation and Mitigation Strategy (REMS) for Extended-Release and Long-Acting Opioid Analgesics (2017) .The FDA provides an overview on the extended-release/long-acting analgesics and provides resources on strategies and how they should be used.
• U.S. Food and Drug Administration. (2015) List of extended-release and long-acting opioid products required to have an opioid REMS.

Prescribing Guidelines Case Examples

• Medical City Healthcare Works to “Crush the Crisis” in Opioid Use (December 2019) Recognizing the nationwide crisis, Medical City Healthcare has employed a comprehensive, three-pronged, system wide approach to reduce administration of opioids. The first phase, focused on reducing opioid therapies in Medical City emergency departments, launched in November 2018. To date, it has resulted in an impressive 21% reduction in opioid use for pain relief in Medical City hospital emergency rooms. The second phase of the initiative aims to reduce opioid use in surgical recovery. The third phase of the comprehensive plan focuses on community education. Read more about this effort and its impact.

• Assessment of Opioid Prescribing Practices Before and After Implementation of a Health System Intervention to Reduce Opioid Overprescribing (Sept 2018). This quality improvement study from the Journal of American Medical Association found postintervention reductions in opioid prescribing occurred at a statistically significantly faster pace than a preintervention downward trend.

• Colorado Hospital Association, Opioid Safety (2018). Colorado Hospital Association and its member hospitals are committed to creating solutions for the opioid epidemic in Colorado. The Association has begun a multifaceted approach to support Colorado’s health care providers in reducing opioid administrations in the ED and providing patients with the necessary addiction treatment they need.
• MetroHealth cuts opioid prescribing by 3 million pills (June 2018).
• Connecticut Adopts New Opioid Prescribing Guidelines for Emergency Departments (April 2018). WALLINGFORD – The Connecticut Hospital Association (CHA), the Connecticut State Medical Society (CSMS), and the Connecticut Chapter of the American College of Emergency Physicians (CCEP) have endorsed an updated set of voluntary opioid prescribing guidelines to help Emergency Department (ED) medical staff treat patients with chronic pain conditions.
• Monterey County Prescribe Safe Initiative: Community Hospital Foundation. (2016) The Prescribe Safe initiative was created by law enforcement, four Monterey County hospitals, and local physicians. Prescribe Safe educates and provides resources for local physicians and patients on the safe use of prescription medications and promotes safe and effective pain management.
• An Educational Intervention Decreases Opioid Prescribing After General Surgical Operations. (2017) The aim of this study was to determine whether an educational intervention was sufficient to decrease opioid prescribing after general surgical operations.
• Physician/Prescriber Reminders When Prescribing Opioids. (n.d.) Jointly issued by the Massachusetts Hospital Association and Massachusetts Medical Society, this document provides a quick checklist of reminders for physicians and prescribers to reference when issuing opioid medication.
• Michigan Opioid Prescribing Engagement Network (OPEN). (n.d.) Michigan-OPEN is a program created to raise awareness among patients and providers, create interventions that reduce postoperative opioid prescribing and patient consumption, and strive for a cycle of continuous improvement.
• Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder. (2017) This resource was created for all emergency departments in Rhode Island. Its intent is to standardize humane, evidence-based care of patients with opioid use disorder in the state’s emergency and hospital institutions.
• Interagency Guideline on Prescribing Opioids for Pain. (2015) This guideline from Washington state offers a balanced approach to pain management that includes recommendations for using opioids when appropriate, such as with acute injuries and flare-ups, for postoperative pain management, and during painful procedures. It also recommends multimodal therapies in general for all chronic pain patients.
• North Carolina Guidelines for Pain Management in Emergency Departments. (nd) The North Carolina Hospital Association developed ED pain management guidelines that the North Carolina Chapter of the American College of Emergency Physicians NCCEP have since endorsed for pain management, which also incorporate CDC guidelines.
• Boston Medical Center - Making Sure Patients Who Need Opioid Meds for Pain Use Them Effectively (November 9, 2017): Adoption of a care model called TOPCARE (Transforming Opioid Prescribing in Primary Care) that incorporates the use of a nurse manager to discuss treatment plans with patients living with chronic pain, as well as online tools for medical professionals and individualized educational opportunities for primary care providers conducted by an expert with expertise in prescribing opioids.
• Safer and More Appropriate Opioid Prescribing: A Large Healthcare System’s Comprehensive Approach (July 2017): Comprehensive initiative to transform the way chronic pain is viewed and treated by creating prescribing and dispensing policies, monitoring and follow-up processes, and clinical coordination through electronic health record integration.
• Conservative Management Clinic – Winona Health, Winona, MN (May 2017): Pain management clinic that uses prescribing guidelines to ensure effective pain treatment and decrease the likelihood of addiction, while also educating patients and providers on painkiller potency and alternative pain-management options.
• Controlled Substance Care Team – CHI St. Gabriel’s Health, Little Falls, MN (March 2017): Team of clinicians that monitors patients prescribed narcotics to treat chronic pain, and connecting them with necessary treatment resources in cases of possible substance use disorder.
• A Multi-Pronged Approach to the Opioid Crisis – Catholic Medical Center, Manchester, NH (February 2017): Providing the hospital’s medical staff with tools to respond to the state’s opioid epidemic, such as electronic medical record programs that identify possible addiction cases, increased provider education on substance misuse, and partnerships with pre-hospital and post-hospital resources.
• Combating the Opioid Crisis: Massachusetts' Path to Action (March 2016) This webinar is about Massachusetts Hospital Association’s development and launch of one of the nation’s most comprehensive and groundbreaking efforts to combat the opioid crisis. Participants learned how the movement gained momentum, task force formation, development and implementation of an innovative action plan including an overview of emergency departments prescribing guidelines adopted by all member hospitals, lessons learned and efforts moving forward.