With opioid addiction still a prevalent problem in the U.S. and overdose deaths occurring at an alarming rate, healthcare providers need to exercise care in how they prescribe. If they don't, then the potential negative consequences are twofold: Patients run the risk of damaging their health due to opioid drugs, and providers open themselves up to medical malpractice claims, which can cost their organizations a small fortune.
Data from the National Institute on Drug Abuse shows the total economic burden of prescription opioid misuse is estimated to be about $78.5 billion a year. That's no small chunk of change.
A new report from Coverys has explored opioid-related malpractice claims in order to identify major risk factors, warning signs and safety vulnerabilities within the pain management process. Among the top findings are that half of all opioid-related cases of malpractice involve a high-severity patient injury, including death.
A full 41% of those claims cite error in the screening and prescribing stage of the pain management process, while 30% of claims cite the monitoring and management stage.
Of those claims citing errors in the screening and prescribing stage, more than 50% of the patients involved had either psychiatric or substance abuse history.
Ann Lambrecht, RN, a senior risk specialist at Coverys and an author of the report, said everybody in the supply chain needs to take responsibility for the problem and work to correct it, not least of all because the $78.5 billion figure from NIDA is likely a conservative estimate, taking into account just those cases that are directly related to opioids.
It can be tricky. Even just looking at the emergency department specifically, many ED clinicians see a patient once and then never again, or perhaps will see a patient who has received care at a number of different EDs, which can make it challenging to truly explore a patient's drug history. Not having a prior relationship with a patient makes it challenging to make a key care decision on the spot.
"Some people who routinely use opioids self-inflict," said Lambrecht. "Even though we say opioids should be limited to certain circumstances, an ED physician faced with someone who has an obvious history … has got to make a split-second decision. It's tough."
SCREENING AND PRESCRIBING
As the numbers in the report indicate, screening and prescribing is the most important stage of the process, and holds the greatest potential for curbing ill-advised opioid prescribing.
"Some people should probably not be on opioids to begin with," said Lambrecht. "A detailed assessment should say, 'Is the pain chronic?' Acute pain should be treated differently than chronic pain."
Clinicians, she said, should be checking the prescription drug monitoring database to see if the patient is taking another medication that could potentially interact negatively with the opioid. When doctors don't access the database, there's a much greater opportunity to overprescribe, or misprescribe.
In one case, a husband and wife were prescribed opioids for pain even though one had 12 such prescriptions and the other had 14. If someone had checked the database, a pattern of drug seeking would have been unearthed, and the new opioids would never have been prescribed. Taking the time to contact a primary care provider may also have alerted care staff to an ongoing problem.
"There are some conditions for which opioids should be restricted," said Lambrecht. "For fibromyalgia, headaches including migraines, back pain, neck pain, sore throat -- for anything that's not chronic in nature, those people should not be prescribed opioids, according to the data we collected."
More than half of the patients whose claims were rooted in the screening stage had a history of psychiatric issues or substance abuse, which would generally be uncovered by peeking into the prescription drug monitoring database -- which admittedly can take some time to access. The rules for accessing the database are more relaxed in some states versus others, but Labrecht said that even if it takes half an hour to cull the necessary information, it's worth it to avoid the negative long-term consequences of inappropriate opioid prescribing, both for the patient and the healthcare organization.
'A STEP AHEAD OF THE GAME'
Staying on top of drug interactions is critically important, even if not all of a patient's drugs were obtained legally. Oftentimes patients with opioid prescriptions will resort to street drugs if they're no longer able to snag pills from a prescriber; Fentanyl and Dilaudid show up in people's systems frequently.
Street drugs, said Lambrecht, should be considered along with any other legal drug a patient may be taking, and should factor into prescribing decisions. Even a patient's history with anti-anxiety or anti-depression medication should be on providers' radars. A general rule of thumb: Reduce the amount of drugs rather than contribute to it.
"We really have to rely on physicians to make decisions," said Lambrecht. "If they know the patient is on these, they're one step ahead of the game."
With half of opioid prescriptions linked to high-severity injury, there should be a checklist in place. Among the most important steps: Assess the patient, check the prescription drug monitoring database, and stay on top of medication reconciliation. That last item can't always be done with trauma patients, but trauma patients don't typically become drug dependent, at least statistically.
Providers should also have a plan in place for tapering medication.
"Emergency room physicians, and hospitals in general, should conduct a little bit of a gap analysis," said Lambrecht. "An opioid self-assessment tool can conduct a gap analysis. Most physicians work in contracted groups and they look to the hospital to have guidelines in place. We ask physicians to talk to the administration to conduct some kind of gap analysis.
"And then for ED groups in general, they should have their own set of prescribing guidelines they agree upon, including the suggestions we've made," she said. "With that information, they can see where their strengths are and where the opportunities are."