AffirmHealth Blog

One of our recent posts, “Prescribing Intelligence: The Role of Data Analytics in Combatting the Opioid Epidemic,” focused on the usefulness of data within clinical decision support tools to help clinicians at the patient bedside.  In that article, we made the key point that “analyzing and accurately indexing data” is a critical hurdle that must be crossed if big data is going to be useful for clinical care delivery.  

In my day to day emergency medicine practice, I routinely treat and manage opioid related overdoses, sometimes as frequently as three or four patients a day. And while the emergency clinical care of an opioid overdose is the same in rural, suburban, and urban emergency departments, I’ve often felt myself wondering what it is that drives the differences in these groups.

The opioid epidemic continues to wreak havoc on the public’s health, wellbeing, and its wallet. In recent years, the regulatory efforts to stem the crisis have significantly decreased opioid prescribing, but not without a cost. Clinicians who prescribe opioids are acutely aware of the regulatory oversight intended to cut down overprescribing, and this has stoked a “climate of fear” when prescribing. As such, patients suffering from chronic pain who have relied on opioid medications for years have reported that their physicians have either stopped prescribing opioids entirely or involuntarily tapered them to doses that do not adequately address their pain.

At AffirmHealth we have focused extensively on covering  our nation's drug crisis -- it’s impact on patients,  physicians and their practices. We have studied the changing laws and dynamics around how practitioners prescribe and the resulting effect on patients. Today we are taking the discussion to the open road, a topic that has been covered by many a country and western ballad and is part of the American way of life.

Task Force Releases Draft Report

The Comprehensive Addiction and Recovery Act of 2016 established a Pain Management Best Practices Inter-Agency Task Force, chaired by Dr. Vanila Singh, under the oversight of the U.S. Department of Health and Human Services.

The Shield platform now integrates with athenaClinicals to help medical group leaders proactively manage and measure opioid prescribing, so they can have the assurance of responsible prescribing across the organization.

A report released in November of 2018, from the Centers for Disease Control and Prevention, show that drug overdoses killed a record number of more than 70,000 Americans in 2017. To put this phenomenon into perspective, drug overdose deaths are higher than deaths from H.I.V., car crashes, or gun violence at their peaks.

We at AffirmHealth report often about the nationwide epidemic, but today we take a closer look at the state of New York. In 2015, New York prescribers wrote 10.2 million opioid prescriptions or 51.3 prescriptions per 100 patients–a 7.8 percent decline since 2013. This is also less than the national rate of 71 prescriptions per 100 patients (IMS Health).

At AffirmHealth, our work focuses around working with clinicians to ensure that they are prescribing opioids in a reliable and compliant manner that gives administrators insight into what is happening across their organizations.  From the clinician’s viewpoint, my job is to help ensure that the clinical information and the decision support we implement works in a way that actually improves care delivery to the patient—after all, if our work isn’t actually making care better, then we’re doing a disservice to the patient.  While our blog has covered a wide range of critical issues around these topics, one thing we’ve never actually discussed is how clinicians should approach the topic of opioid abuse with their patients, strategies for successful risk screening, and what to do if one of your patients develops an opioid use disorder.

In November of 2018, the DEA released the results of the 2018 National Drug Threat Assessment. The 164 page report highlighted the threats posed to the United States by domestic and international drug trafficking and the abuse of illicit drugs. The DEA’s acting administrator, Uttam Dhillon, said the assessment “underscores the magnitude of the nation’s opioid crisis and highlights the necessity of using all the tools at our disposal to fight this epidemic.”¹

The Opioid Epidemic in America is a topic covered extensively, each and every day in the news. AffirmHealth covers this topically frequently as well, most recently in our, "Where are We Now?" article.

For those of us involved in the opioid epidemic as caregivers, patient advocates, and researchers, there was an interesting moment earlier this year when a series of news stories noted some optimism in the fight against overdose deaths. 

In mid-October, Health and Human Services Secretary Alex Azar commented on preliminary data from the U.S. Centers for Disease Control and Prevention that suggested “that the U.S. may be ‘beginning to turn the tide’ on the opioid crisis.[1]”  “The seemingly relentless trend of rising overdose deaths seems to be finally bending in the right direction…We are so far from the end of the epidemic, but we are perhaps at the end of the beginning.[2]” 

As the opioid misuse and overdose epidemic impacts communities across America and has sweeping global implications, practitioners are looking to the future of pain management and the novel treatment options that may be on the horizon.

Earlier this month on November 2nd, the U.S. Food and Drug Administration approved Dsuvia, a new sublingual version of an older drug, sufentanil, that has been in use since 1984. 

Last week on the AffirmHealth Blog we discussed MIPS and PDMP Usage and promised a follow up on additional Improvement Activities. So this week we look at an Improvement Activities Data overview as well as a handful of activities potentially pertinent to providers prescribing opioids or other controlled substances.

Let’s start at the beginning…

MIPS: What is it and what do prescribers need to know? 

A Focus on Opioid Education Efforts

Naloxone is a medication approved by the Food and Drug Administration (FDA) to prevent overdose by opioids it is designed to rapidly reverse opioid overdose. Commercially, it has been available for almost 50 years and several formulations are available, produced by various manufacturers. 

Everyday the media is flooded with stories about the toll of opioid addiction in America. New rules and regulations are regularly being introduced on a state and national level as we collectively grapple with how to tackle this epidemic. However, the war on opioids in America is not new. In 2011, the Centers for Disease Control warned that prescription painkiller overdoses had reached what was considered “epidemic levels.”

At AffirmHealth, we’ve directed much of our blog content towards safe and responsible opioid prescribing practices with an emphasis on the application of state and federal guidelines to daily clinician activities. 

On Monday, in a bipartisan move, the Senate overwhelmingly passed legislation aimed at combating the opioid epidemic.

Pharmacy Times reports that, "The first PDMP program was enacted by New York State in 1918 and was used to monitor prescriptions for cocaine, codeine, heroin, morphine, and opium. With this program, pharmacists were required to report copies of prescriptions to the health department within 24 hours."

Oklahoma recently became the 30th state in the US to allow access to medical marijuana. The proposal, which passed by a 57% to 43% margin allows doctors to recommend cannabis for any medical condition they deem medically necessary. This makes Oklahoma's law one of the least restrictive in the country.

TN Together Opioid Charts: A Legislative Update for the state of Tennessee regarding opioid prescription requirements for healthcare providers

Ohio led the nation in opioid overdose deaths in 2014, and deaths have continued to rise with increased use of heroin and illegal fentanyl - fentanyl-related deaths surged from 75 in 2012 to 1,155 in 2015.

Any change, even a change for the better, is always accompanied by drawbacks and discomforts." -Arnold Bennett

As an organization, part of our mission is to provide up-to-date information on opioid related news as well as state and federal guidelines and regulations for opioid prescribing. Our resource library is designed to educate healthcare professionals in order to facilitate better opioid prescriber compliance across healthcare organizations. Our software platform, Shield, incorporates the applicable state and federal regulations clinicians must adhere to, enabling healthcare systems to prescribe opioids more responsibly. 

On July 1, 2018 the Controlled Substance Bill became effective in the state of Florida. “There is nothing about this law that means legitimate patients cannot get legitimate medicine for legitimate reasons,” Dr. John Ellington, who is in charge of risk management at the 200-physician Watson Clinic in Lakeland, Florida is quoted as saying.

“The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.”—Atul Guwande.[1]

We directly attribute AffirmHealth's traction to our team's passion to aid in the fight against the ongoing opioid epidemic. Every employee has been personally affected by the crisis--two of our founders are from small, rural towns in the crosshairs of the crisis and our third founder (an ER physician by training) works on the front-line and sees the epidemic's impact daily. Our personal experiences led to a unified, burning passion to help and that is what drives us every day.    

Starting July 1, 2018 doctors who prescribe opioids in Tennessee face stricter guidelines and checkpoints before beginning acute or long term opioid therapy (COT: Chronic Opioid Therapy) for their patients. Additionally, the new laws will incentivize offenders to complete substance use treatment programs in prison and make dealing fentanyl and other dangerous substances second-degree murder when it causes a death. Recovery high schools, partial dispensing of opioid prescriptions and Buprenorphine prescribing restrictions are also included.

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

Last year, 1,404 people died of drug overdoses in Kentucky, according to the Kentucky Office of Drug Control Policy.  Of those, roughly half  involved fentanyl, a powerful synthetic painkiller that we originally discussed in "The Word on the Street."   In response to this ongoing trend, Kentucky is one of a handful of states that have been at the forefront of PDMP improvement as well as increased opioid legislation.   Here, we discuss the enhancements to Kentucky's PDMP system, KASPER, as well as some of these important pieces of legislation.

To address our nation's opioid epidemic, states are increasingly taking action at the prescription level. This includes enacting mandates on prescribers and their controlled substance prescriptions. Legislators have focused on opioid prescriptions in order to prevent overprescribing, and the resulting regulations primarily fall into four categories:

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

In December of 2017, Michigan’s Lt. Governor Brian Calley signed  a comprehensive 10-bill package to address Michigan’s opioid epidemic, substance abuse and drug diversion problems. The multi-faceted package addresses various education initiatives from school aged children to patient informed consent and also covers acute pain prescriptions, MAPS and a variety of other topics impacting the prescribing of controlled substances in Michigan.

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

The rumors are out there, maybe even whispers in your waiting room. The news is flooded with tales of the opioid epidemic and more increasingly the drug fentanyl. A quick Urbandictionary.com search tells us that fentanyl has many nicknames including china white: defined by a site user as “a pure/raw or high grade heroin, mixed with the powerful synthetic painkiller, fentanyl. Combined, these two create a very very high grade painkiller.”

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

We’ve previously written about the challenges clinicians and patients face as they seek non-opioid alternatives for effective pain management.  One such alternative, Mitragyna speciose, or kratom, has been a focus of increased public discussion lately, but is still a topic that many clinicians are unfamiliar with.  AffirmHealth has developed this short primer to help bring you up to speed so that you can have an informed discussion with your patients.

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

Determining when to taper 

We hear a lot about opioid tapering from multiple different sources these days. It is mentioned in CDC guidelines and we get it from insurance companies as well. It seems that the insurance companies are trying to force you to taper all of your patients off of opioids, but as clinicians we know that some patients benefit from them and need them to maintain quality of life. So, how do we know who should be tapered? For me, the answer lies in the balance between risks and benefits. When the risks of any medication outweigh the benefits, then we should stop it. These risks can also be applied to the community if a patient is diverting their opioids.

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

Patients with chronic pain are frequently asked to agree to medication adherence activities, like pill counts as a part of an opioid therapy plan. We dig into what pill counts may look like, how they are facilitated, and the potential pitfalls they present.

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

Amidst the opioid and chronic pain crises in the United States, many of us on the front lines of clinical and research medicine have been searching for opioid alternatives that we can safely use to manage our patients’ pain. 

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

Treatment Agreements and Informed Consent. If your practice prescribes opioids, you need them. But what are they and how do they differ? We dig into each and how they impact your practice and your patients.

On Saturday, April 28, from 10 a.m. to 2 p.m. the Drug Enforcement Administration will partner with local agencies across the country for the 15th Take Back Day. This opportunity is another initiative to prevent pill abuse and theft by ridding homes of potentially dangerous expired, unused, and unwanted prescription drugs. The DEA cannot accept liquids or needles or sharps, only pills or patches. The service is free and anonymous.

Urine drug testing (UDT) is a critical tool for patients on chronic opioid therapy.  It is also one of the most misunderstood. 

As most states have updated their opioid prescribing guidelines over the past two years, nearly every one now includes a requirement to conduct urine drug screening in certain populations. Unfortunately, many of these recommendations have been developed in isolation with variances across the level of testing to conduct, testing frequency, and guidelines required for medical necessity.

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

This month the Center for Medicare & Medicaid Services (CMS) published new limits for high-dose opioid prescriptions for Medicare Part D users. The announcement is part of the 2019 Medicare Advantage and Part D Rate Announcement and Call Letter.

The policy also follows the CDC opioid prescribing guidelines for primary care physicians released last year. High dosage thresholds outlined include parameters for prescriptions greater than 90 MME, which state a pharmacist should consult with prescriber and document the discussion. At 200 MME, a hard cap is implemented that can only be overridden by the plan sponsor. Additional guidelines for opioid naïve patients were also included, limiting initial opioid prescriptions to no more than a 7 days’ supply for the treatment of acute pain.

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

In Medscape’s article “Talk About Pain,” R. Morgan Griffin states, “One of the hardest things about chronic pain is that only you know how bad the pain feels. There's no blood test that can show much you're suffering. There's often no outward sign, like a bandage or a cast. There's just the pain." 'Pain is always personal,' says F. Michael Ferrante, MD, director of the UCLA Pain Management Center in Los Angeles. 'It's invisible to other people looking at you -- and that can lead to a lot mistrust and difficulties in relationships.'"

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets, the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

The staggering rate of prescription opioid misuse, abuse, and overdose has placed a heavy burden on prescribing clinicians and their practices. Federal and state regulators have responded by enacting extensive opioid prescribing guidelines. Across the board, these guidelines prioritize the importance of properly assessing a patient’s risk of misuse or abuse.

With opioid prescribing regulations being updated, national policy announcements, state guidelines as well as daily commentary regarding the opioid epidemic flooding news outlets; the AffirmHealth Weekend Round Up looks at the top headlines that caught our team’s eye. From controlled substance protocols to research focusing on pain management, addiction medicine, the ER and more...provided to you in an easy to access summary. News you can use. Welcome to the Weekend Round Up.

This afternoon in New Hampshire, a state hit particularly hard by the opioid epidemic, President Trump announced a three part strategy to combat the worsening crisis.  Opinions about the approach have been mixed with some calling it a return to "a comprehensive drug policy," while others are concerned that a heavy focus on punitive measures will limit efficacy.  Here's our summary:

Happy Spring Break! A few of the news stories that caught our eye at AffirmHealth this past week.  

Some of the news stories that caught our eye at AffirmHealth for the first week of March:

On February 15, 2018, SAMHSA released updated Treatment Improvement Protocols (TIP 63) for Opioid Use Disorder. We poured through the 306-page mega-manual to bring you the highlights.

Some of recent the stories that caught our eyes at AffirmHealth in February:

Why you need prescribing protocols

In an effort to combat the opioid epidemic, state and federal governments continue to introduce regulations and guidelines for prescribing controlled substances. In addition, insurance payers have issued policies for prescribers. 

While these guidelines and policies have assisted in the fight against the opioid epidemic, they aren’t static or consistent and have left prescribers overwhelmed with trying to keep up.

As the opioid epidemic continues to dominate our national attention, states are enacting rules on opioids, on benzodiazepines, and other controlled substances. 

The Challenges Facing Pain Management Clinicians

Managing pain patients can be a scary thing these days. It seems that every time I open the newspaper or check my email I read a story about a doctor getting into trouble of some sort or another related to prescribing opioids. There are cases of doctors being federally prosecuted and convicted of criminal charges, instances of physicians losing their medical licenses from state medical boards, and plenty of examples of providers getting dropped from insurance networks for having prescribing patterns that don’t line up well with the company’s metrics. As such,  companies now examine claims data from insurance companies and measure the performance of healthcare providers relative to their peers or other set measures. These comparisons can then be used against those providers. In short, with constantly inscreasing regulations around prescribing and managing chronic pain, there is no shortage of ways to get into trouble when it comes to prescribing controlled substances.

Defining Patient Risk and the Challenges of EHR Integration

How does your practice define patient risk to decide the services you may provide, the laboratory tests you may order and/or the prescriptions you may write? Another important question in today’s environment--How do you document these multi-layered facets within your EHR system?

Treating chronic pain in 2018?

One of the questions we get most frequently when we discuss AffirmHealth is, “who are your customers?”  It’s a fair question and broadly speaking, our customers are two-fold:  clinical providers and the patients they serve.  The second follow on question that occasionally comes up is, “do you want to get rid of all opioids?”  To be clear, our goal is not to eliminate opioids.  In fact, we firmly believe in the viable role that opioids have in pain management.  But we also believe that responsible opioid prescribing must be practiced within the boundaries of a relationship founded on trust between the physician and the patient.  Our products are designed to help develop that relationship so that both providers and patients can manage these prescriptions as safely as possible.  Recognizing that different medical specialties have different regulatory demands, we offer solutions in three practice areas:

When we first founded AffirmHealth in April 2016, we had one goal:  to make opioid prescribing safer for patients and providers.  We did that by automating state opioid database queries so that they integrated with clinicians’ workflow and improved patient safety, maximized provider efficiency, and fixed a headache for both patients and providers.  In 2018, we are going to be dramatically expanding that offering and I wanted to spend some time explaining our value proposition and how we support practices that use our services.  Our focus is still the same:  we recognize that opioids have a critical role in the management of pain.  But even one overdose is too many.  Our goal is to make sure we help drive that number to zero.

This past week, several of our nation’s public health experts testified on Capitol Hill before the Senate Health, Education, Labor, and Pensions Committee.[1] They made the concerning argument that despite all of the effort and attention being cast on the national opioid epidemic, we are failing to make significant progress. In fact, we are continuing to lose ground and opioid related deaths continue to accelerate across the country.

With all of the recent attention cast on the national opioid epidemic and the increase in overdose deaths, one issue that seems to have fallen out of focus is the need for increased scrutiny on concomitant drug prescriptions, particularly benzodiazepines. The combination of opioids and benzodiazepines was found to be dangerous enough that dual prescribing of the two medications caused the FDA to issue black box warnings when prescribing each of these medications in 2016. An article originally published in Clinical Advisor (March 2017[1]) makes two important points:

At AffirmHealth, we're passionate about improving the processes needed to manage chronic pain safely.  In the past, I've written several times about the patient-physician relationship and the complex parts of managing those relationships in the setting of our national opioid epidemic.  This morning, CNN published an interesting article that highlights another side of the problem:  the increasing legal issues that physicians are facing as they navigate the pain management landscape.  I share it here not so much to give a direct opinion on the issue, but because I feel that it's important that we all engage in a discussion informed by everyone's viewpoint.  This article goes a long way to sharing the evolving physician and law enforcement perspective.  The following is directly reprinted from CNN:

A few days ago, Mark Jarrett penned a provocative online op-ed on The Hill website, “Congress, take an Ebola inspired approach to the opioid epidemic.[1]”  He made several interesting points including the following:  in 2015, the opioid epidemic claimed 33,000 American lives compared to 11,000 worldwide from Ebola from 2013 to 2016.  During a period from 2014-2015, I was fortunate to serve as a White House Fellow and Acting Director for Pandemic and Emerging Threats at the U.S. Department of Health and Human Services and was intimately involved with the domestic and international Ebola response so I found this point particularly remarkable.  Without question, the Ebola outbreak was a full blown international crisis, so it’s quite striking that our own domestic health crisis around opioid abuse is only now beginning to get the full attention it deserves even though the scale of magnitude is three times greater than the Ebola epidemic.  I believe there are many reasons for this including the particularly heinous way that Ebola causes disease and its portrayal in popular media.  At the same time, I suspect that the relatively insidious onset of the opioid epidemic and the fact that these medications are often prescribed legally by medical professionals allowed us to look the other way while it took its full hold.  Either way, we now find ourselves in the midst of a national crisis that is claiming close to 100 American lives every day.

Looking to stay compliant with state prescribing guidelines? Check out our related content:

• Opioid Prescribing in 2018
• State-by-State Prescriber Resource Guide

In March 2016, the Center for Disease Control (CDC) made headlines when it released it's 12-point Guidelines for Prescribing Opioids for Chronic Pain. As the opioid epidemic and chronic pain pandemic have reached record levels, state governments and professional medical societies alike have released their own recommendations and regulations to inform opioid prescribing. Here's a snapshot to help you keep track of your state's chronic pain guidelines.

The Accreditation Association for Ambulatory Healthcare, Inc. (AAAHC) has released a new toolkit to combat opioid overdose through improved stewardship programs. The resource is designed to help providers review and assess the volume and length of opioid prescriptions and dosages to mitigate risk of patient overdose and death.

By now, much has been written about Tiger Woods and his recent arrest for driving under the influence in Florida.  The professional golfer was found slumped over the steering wheel of his car with the engine still running and damage to the side of the vehicle.  When officers performed a field sobriety test, his breathalyzer indicated that he had not ingested any alcohol and it is likely that he had a mixture of non-steroidal anti-inflammatory and narcotic medications in his bloodstream—some reports indicate that he was taking Vioxx as well as Vicodin (in addition to other medications).^[1]  In her recent report for The Atlantic, Olga Khazan does a great service using this incident to highlight the problem of drivers not under the influence of alcohol, but severely impaired by prescription medications.

After reviewing several articles regarding the controversy chronic pain patients are facing due to physicians changing policy in fear of the CDC Opioid Guidelines, I feel it necessary to address the seriousness of turning away legitimate chronic pain patients seeking medical care, because of the perceived stigma attached to opiates.

The Hudson Institute’s recent briefing paper, “A Strategy to Counter the Opioid Epidemic: Contain, Reduce, Extinguish” delivers a clear explanation of our nation’s opioid problem, and importantly, a comprehensive approach to address the issue.

First, Let's Talk About My Pain.

Pain can be explained as either chronic or acute. Acute pain is described as pain that has just occurred after an injury such as surgery or trauma to our body. Acute pain will improve over time as our bodies heal from this injury or surgery.

A recent study published in The Journal of Pain found that patients prescribed higher opioid doses experienced greater pain intensity, higher health care utilization, and poorer quality of life. Is this a breakthrough finding or an obvious correlation?

Saturday, April 29th is National Prescription Drug Take-Back Day, a part of the Drug Enforcement Administration’s initiative to provide a safe and easy way to dispose of unused prescription and over-the-counter drugs.

As both a practicing emergency medicine physician, and Chief Medical Officer at AffirmHealth, a local company dedicated to combatting opioid abuse, I spend a significant amount of time thinking about the right approach to fighting opioid misuse in Tennessee, my home state. David Plazas’s editorial on April 2^nd, 2017 rightly draws attention to the opioid epidemic which he characterizes as “Tennessee’s No.1 public health crisis” and his point about the medical vs. criminal management of addiction is a good one. There’s no question that addiction is a multifactorial disease process and our worsening crisis is unlikely to be solved through a law and order approach alone. It’s going to require individualized solutions that tailor therapy based on each addict’s needs.

Let's face two truths about heathcare costs in our country:

1. We spend over $600 billion annually in pain treatment and resulting lost productivity
2. The top 1% of 'high utilizers' account for over 27% of total costs

In previous blog posts, I’ve written about the work we’re doing at AffirmHealth to combat the growing opioid epidemic in our country. With Dash, we’re working to help clinicians access prescription drug monitoring programs as efficiently as possible with an eye toward driving clinical decision support based on scientific guidelines.

As a both a practicing emergency medicine physician, and Chief Medical Officer at AffirmHealth, an organization dedicated to combatting opioid abuse in this country, I spend a significant amount of time thinking about the right tools we need to develop to make pain management practices more effective. In the clinic, healthcare providers are operating at a time when we have never had more information about our patients readily available. Conversely, however, this wealth of information often creates the challenge of “too much noise; too little signal” and it can be easier to fall into the trap of simply maintaining old practice patterns that have worked for us in the past. Unfortunately, the outdated practices of yesterday will not be enough to effectively reverse the worsening opioid epidemic in our country.

In recent years, the opioid abuse epidemic has taken center stage in the United States.  From stories in local newspapers, to nuanced discussions about the best policy solutions Washington can offer, it seems most people are in some way aware of the current crisis.  One of the most effective methods used to combat the rise in narcotic-related overdoses has been the implementation of prescription drug monitoring programs (PDMPs) by 49 of 50 states.  These systems help to track controlled substances – who is prescribing them, who is receiving them, how much is prescribed and how often, etc.  While there is a lot of emphasis on the role physicians play in PDMPs being a meaningful tool, an important member of the healthcare team is often overlooked – the pharmacist. 

A recent Washington Post article highlights the fact that states are quickly adopting comprehensive mandates requiring doctors who prescribe opioids and other controlled substances to check a patient’s prescription history within the statewide database (prescription drug monitoring program – PDMP). To date, eighteen states have implemented these mandates and it is likely that adoption will continue to increase in the coming months and years.  Bottom line—mandates are here to stay.

This morning, I read with great interest the Centers for Medicare and Medicaid Services (CMS) Opioid Misuse Strategy. As I’ve written about in prior blog posts, and as others have also noted in a variety of fora, our country is experiencing a profound opioid crisis across all socioeconomic classes of our society. As the U.S. Surgeon General, Dr. Vivek Murthy recently commented, physicians are partially to blame for the problem as we’ve misprescribed these medications under the pretense that they were not addictive when used to manage legitimate pain. We now know that to be untrue and CMS statistics clearly show that physician prescribing practices have accelerated the problem. The document highlights four priority areas for action including:

Our nation is in the midst of an unprecedented opioid epidemic. The growth of the opioid crisis has generated an outcry for more resources to fight addition and provide proper treatment. Policymakers and public health officials are increasingly using new tools such as prescription drug monitoring programs (PDMPs)—state-based electronic databases that track the dispensing of certain controlled substances, including prescription opioids—to curb misuse and reduce overdose deaths. While PDMPs have been proven to be effective, the number of prescribers using these databases in clinical care remains low[1].

A recent analysis from health and medicine newsletter STAT examines the correlation between medicinal marijuana availability and opioid overdose deaths.

Are you suffering from chronic pain?

As a clinician in America today, there can be intense pressure to focus on multiple things at once. Our priority is providing high quality patient care, delivered in a timely and safe manner.  Patient care has to be the focus every day. Everything is built on that.  Unfortunately, it’s all of the other changes going on in medicine that make it increasingly difficult to maintain that focus.  Today, I can’t open a medical journal, or walk into the hospital, without thinking about words like bundled care, value based delivery, and disruption. And the more I try to learn about it, the more chaotic the whole thing seems to become.  I’m constantly considering how new government mandates and payment reform are going to influence our ability to keep our practices operational and profitable.  But regardless of how much turmoil exists, I’ve come to realize that this is the new normal in American medicine.  This type of disruption and instability will be here to stay not only because patients are consuming health care differently, but also because the financial pressures to develop cost containing measures while still delivering quality care are strengthening.

Last Friday, CMS released the final rules for MACRA, a program that represents a fundamental shift to the way providers are reimbursed by Medicare.  The rule is designed to give physicians more flexibility to provide high quality, safe, and effective care.  But, it’s important to know that the rule can impact your income both positively or negatively.

As prescription opioid use and abuse has surged over the past decade [1], Prescription Drug Monitoring Programs, or PDMPs, have become a cornerstone of state opioid prescribing guidelines in efforts to help promote responsible opioid prescribing. Let’s drill down into the basics of the programs.