Peer-approved prescriptions, drug-gene testing and electronic prescribing may be the wave of the future in the war on prescription opioid abuse. Those were some of the key takeaways for more than 60 physicians from around Florida at a recent Opioid Summit. Dr. Abraham Rivera, chief medical officer of Physician Partners of America, served as presenter of the April 28 event in his role as board member of the Florida Academy of Pain Medicine (FAPM).
“The legal landscape is changing, and we need to change the way we prescribe,” said Dr. Rivera, an interventional pain management specialist and anesthesiologist.
The Opioid Summit seeks to define the scope of the growing abuse problem and ways to solve it. Among the speakers was U.S. Rep. Gus Bilirakis, R-Florida, as well as representatives from law enforcement and the legal field. The presentations focused on responsible prescribing, transparency and alternative treatments.
Avoiding Prescription Opioid Abuse
In the absence of uniform prescribing laws and indications, opioid painkillers should be used as a means to an end, not as an end by itself. Drug tapering and detox protocols should be used routinely and all prescriptions should follow a specific diagnosis, with no off-label prescribing. Sustained release opiates should be used no more often than twice a day. Short-acting opiates are used no more often than four times daily. Electronic prescriptions are encouraged for a variety of reasons: they provide solid documentation from the beginning of treatment and they do not get lost. There is also less potential for abuse, diversion and tampering.
Finally, the summit proposed that opioid prescription records should be monitored by a physician’s peers for review. “Accountability and transparency are key,” Rivera said.
Changes in Opioid Laws
Like many states, Florida is clamping down on prescription protocols. A new law that goes into effect July 1 limits such prescriptions to three days – seven in cases deemed medically necessary. The laws address people who suffer from acute pain, but more discussion is needed to address the needs of chronic pain patients. Those are defined as people who experience pain for more than 12 weeks.
Dr. Rivera’s take: “Every case is different, but in general, a one-month supply is reasonable for chronic patients.”
Interventional Pain Management
To Physician Partners of America, the answer lies in interventional pain management. This subspecialty of pain medicine seeks to pinpoint and treat the pain at its source without relying on prescription opioid medication.
Interventional treatment includes:
- Epidural injections
- Facet blocks
- Radiofrequency ablation
- Nerve blocks
- Corrective surgery
- Intrathecal pumps
- Neurostimulation
Dr. Rivera also recommended that physicians explore alternative treatments such as Traditional Chinese Medicine, acupuncture, chiropractic and massage.
Monitoring Pain Patients
Physician Partners of America recommends performing urine drug tests (UDTs) on pain patients, starting before the first prescription is written and then when indicated. The frequency varies according to individual patient risk.
In addition, prescriptions should not be copied or given to the patients at office visits. The system is not foolproof, however. Roadblocks include lack of communication between states and the Veterans Administration, and the fact that some states do not have this system.
Legislating Opioid Prescriptions
Recommendations include using prescription drug monitoring programs (PDMS) for every prescription. The summit’s presenters also recommended fuller implementation of the National All Schedules Prescription Electronic Reporting Act (NASPER). Enacted in 2005, this U.S. Department of Health and Human Services program gives grants to states to start or enhance prescription drug monitoring programs.
Rep. Bilirakis discussed the intent of Congress to fund programs to help with the opioid crisis across the nation. He noted that the House has passed legislation to address this issue, but the Senate has yet to bring it up for discussion.
Is Naloxone the Answer?
For those patients who are still opioid users, the summit presented an innovative approach: prescribing a companion prescription of the opioid antidote Naloxone to prevent accidental overdose. The U.S. Surgeon General recently endorsed this idea. Since its inception, PPOA has encouraged its physicians to prescribe an antidote to every patient who is prescribed an opiate in excess of 50 mg. per day of morphine equivalents.
Alternative Pain Therapies
Interventional pain management should be considered as a first course of treatment for select pain patients as an alternative to a prescription opioid. It gets to the root of the problem and provides direct relief. Interventional treatment includes:
- Epidural injections
- Facet blocks
- Radiofrequency ablation
- Nerve blocks
- Corrective surgery
- Intrathecal pumps
- Neurostimulation
Intraoperative Neuromonitoring (IONM)
Intraoperative neuromonitoring is also being used to reduce pain following surgery and, therefore, the use of narcotic painkillers post-operatively. IONM is designed to minimize neurological damage during surgery. It identifies changes in brain, spinal cord, and peripheral nerve function prior to accidental, irreversible damage.
Pharmacogenomics
Medication efficacy is determined in part by genetics. What works for one person is likely to be different form another. Drug-genes testing is routine at PPOA, ensuring that the safest doses of the right medications are administered.
The ideas presented at the summit are likely to spark further discussion at the FAPM’s annual conference in July at the Orlando Grand Hyatt. And while approaches differ, pain management physicians are changing their way of thinking about a prescription opioid as a first course of treatment.
“Opiates should be used as a means to an end,” Dr. Rivera said, “and not as an end by itself.”
